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Carers Self Assessment form


This form is only to be completed by people caring for someone over the age of 18.

Please only complete this form if you are a carer looking after an elderly, sick or disabled relative, friend or neighbour who is over the age of 18 and you would like to see if you are entitled to any services that could make this easier.
 
To help us with your carers self assessment please answer as many of the following questions which best describe your situation.
 
For urgent enquiries, please call us on 01234 267422.
 
For emergency referrals outside of usual hours please contact the Emergency Duty Team on 0300 300 8123.
 

Data Protection Act 1998

Please note that the personal details supplied on this form will be held on a file and/or computerised by Bedford Borough Council for the purposes of recording carer self assessments to the Adult Social Care team. Your personal details may be shared internally within the Council for this purpose, but will be safeguarded and will not be divulged to any other individuals or organisations for any other purposes. In exceptional circumstances we may be required to exchange this information as laid done by law, in accordance with our Data protection policy.
All personal information collected will be covered by our Privacy policy.
 
By submitting this form it is assumed you have given consent for this information to be shared amongst any Adult Social Care staff who may be involved.
 
This eform will be sent in a secure/encrypted format and will only be accessed by the relevant Adult Social Care staff.
 
Confidentiality is assured.

Any fields marked with a '*' are mandatory fields, all other fields are optional.
 

Please enter your details as a carer.

Title
Title
Gender
Gender
 
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Bedford Borough Council
Borough Hall
Cauldwell Street
Bedford
MK42 9AP

Tel. 01234 267422