Emergency Card Registration

to be completed by carers wishing to ensure a plan is in place for the person being cared for

Emergency Card Registration Form

"*" indicates required fields

Who Runs the Scheme?
Barnet Home Carers, our homecare service run the scheme on behalf of the London Borough of Barnet. It operates 24 hours a day 7 days a week.

How Does the Scheme Work?
Stage 1
In order to apply for the emergency card scheme you must first register as a carer. Once registered, you will receive a unique carer reference number which you will need to complete the emergency card form. You can find our registration form here: Register as a Carer - Barnet Carers

Stage 2
In completing this registration form, you will be asked to nominate three emergency contacts who can step in and check on the person being looked after if you are unable to do so. They will be contacted by our homecare team, Barnet Home Carers if an emergency occurs.

Once we have your registration form we will keep this with us, you will then be given a Carers Emergency Card with a helpline number to call if an emergency arises. Anyone finding this card on you will also be prompted to call.

Stage 3
We may be unable to get a hold of your emergency contacts or they may not be able to attend to the person straight away. If this is the case we will deploy one of our own support workers typically within 2 hours of the emergency occurring.

If the emergency lasts longer than 48 hours (2 days) then Barnet Carers Centre will put other arrangements in place with support from Adult Social Care and the person’s family. The support worker asked to step in will be provided with a copy of your registration form which also acts as a support plan for the person you care for.

Please complete the questions below

Carer's Name*

Carer's Date of Birth*

DD slash MM slash YYYY

Carer's ID Number*

This number will be sent to you once you have registered as a carer.

Please enter the postcode below and click on the Lookup Postcode button

Carer's Address*

City*

Postcode*

Primary Contact Number*

Secondary Contact Number

Email*

Relationship to Person Being Cared For*

LBB Reference Number (if applicable)

Person Being Cared For's Name*

Person Being Cared For's Date of Birth*

DD slash MM slash YYYY

Please enter the postcode below and click on the Lookup Postcode button

Person Being Cared For's Address*

City*

Postcode*

Primary Contact Number*

Secondary Contact Number

LBB Reference Number (if applicable)

Does the person have a Lifeline (telecare alarm) from Barnet Carers?

Yes

Other Professional People Involved with the Person Being Cared For

Name (Social Worker/Practitioner)*

Telephone Number*

Address (Social Worker/Practitioner)*

Name (GP)*

Telephone Number*

Address (GP Surgery)*

Name (Other e.g. Home care agency)

Telephone Number

Address (Other e.g. Home care agency)

Further Details of the Person Being Cared For

Please give brief details of their disability, illness or any relevant medical information*

Can the Person Being Cared For answer the front door?*

Yes

Can the Person Being Cared For answer the telephone?*

Yes

Who holds keys to their home?

Who knows where to get the keys?

Does anyone else live with the Person Being Cared For?*

Yes

Name*

Contact Number*

Does the Person Being Cared For have any regular time away from the home? (e.g. at a day centre, college, respite)

Yes

Please give details including where, days and times if applicable.

Emergency Contact Details
Please list up to 3 contacts e.g. family, friends, neighbours who have agreed to look after the cared for person in an emergency situation. If you have only one contact or no contacts, please consider other alternatives, e.g. home care agency, social worker, Social Care Direct (tel 0208 359 5000).

Before you complete this section, you MUST ask the person if they agree to be the emergency carer and for their details to be given on this form.

Name [Emergency Contact #1]*

Relationship to Person Being Cared For*

The named individual has been asked [Emergency Contact #1]*
I confirm that I have asked the named individual to be an emergency contact

Address [Emergency Contact #1]*

Primary Contact Number [Emergency Contact #1]*

Secondary Contact Number [Emergency Contact #1]

Do they have access to keys to the Person Being Cared For’s home?*

Yes

No

In what way can they help the person requiring care and support?*

Name [Emergency Contact #2]*

Relationship to Person Being Cared For*

The named individual has been asked [Emergency Contact #2]*
I confirm that I have asked the named individual to be an emergency contact

Address [Emergency Contact #2]*

Primary Contact Number [Emergency Contact #2]*

Secondary Contact Number [Emergency Contact #2]

Do they have access to keys to the Person Being Cared For’s home?*

Yes

No

In what way can they help the person requiring care and support?*

Name [Emergency Contact #3]*

Relationship to Person Being Cared For*

The named individual has been asked [Emergency Contact #3]*
I confirm that I have asked the named individual to be an emergency contact

Address [Emergency Contact #3]*

Primary Contact Number [Emergency Contact #3]*

Secondary Contact Number [Emergency Contact #3]

Do they have access to keys to the Person Being Cared For’s home?*

Yes

No

In what way can they help the person requiring care and support?*

The Person Being Cared For (their support needs)

For how long could the person you look after be safely unsupervised?*

Does the Person Being Cared For take any medication?*

Yes

No

What medication do they take?*

Where is the medication kept?*

Does the person you look after need help with the following:

Help with medication*

Yes

No

Please give further details*

Personal care e.g. bathing, dressing*

Yes

No

Please give further details*

Preparing food/drinks*

Yes

No

Please give further details*

Managing toilet needs*

Yes

No

Please give further details*

Communication needs (include preferred language)*

Yes

No

Please give further details*

Mobility, e.g. walking, wheelchair user*

Yes

No

Please give further details*

Seating/posture, e.g. getting on/off from bed/chair*

Yes

No

Please give further details*

Emotional support, e.g. anxiety, depression*

Yes

No

Please give further details*

Social/leisure activities*

Yes

No

Please give further details*

Managing bills etc.*

Yes

No

Please give further details*

Any known risks, e.g. falls, self-harm, going missing*

Yes

No

Please give further details*

Behaviour issues, e.g. verbal, physical*

Yes

No

Please give further details*

Additional needs, e.g. dietary, allergies*

Yes

No

Please give further details*

Do they have any pets, e.g. large dogs*

Yes

No

Please give further details*

How did you hear about Barnet Carers Emergency Card Scheme?*

Please specify

Your Consent to Sharing Information

I give consent for this plan to be shared with Barnet Council, named people in the form and any other health and social care professionals/ agencies that may be involved in providing emergency care. I have obtained the permission from the people named in Section 5 (my emergency contacts) for them to be named as emergency contacts and their details to be shared in this way.*
Yes
No

I give consent for Barnet Carers Centre to contact the Emergency Services, e.g. police, ambulance in case of an emergency, where the person you look after is in need of support, is at risk of harm and/or if none of the key holders are reachable in order to gain entry to the home.*
Yes
No

Emergency Card Registration

Emergency Card Registration Form

Please complete the questions below

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