Social Prescriber Referral

to be completed by a social prescriber wishing to refer a carer.

Online Carers Self Assessment PQQ

"*" indicates required fields

The following carers assessment has been created by Barnet Carers, with its aim being to ascertain how all aspects of your life may be affected by your caring role. By answering these questions, and by working collaboratively, we aim to support you through your enablement journey to reach a point where it is as good as it can be.

Personal Information and Contact Details

We need to collect some basic personal details from you such as your date of birth and address. These will only be used to provide you with support that is identified as part of this carers assessment.

I give consent for this assessment to be shared as needed with other agencies involved in my care*

Yes

Yes, but with restrictions

Other

You have selected - 'Yes, but with restrictions' Please give details of requested restrictions*

You have selected - 'Other' Please give details of specified consent*

Are you already registered with Barnet Carers?*

Yes

Are your details still up to date?*

Yes

Not Sure

This is just to ensure that your details are checked and updated on our database

Please enter any known changes to your contact details*

Name*

Prefix First Last

How would you like us to address you?

Gender*

Date of Birth*

DD slash MM slash YYYY

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

Address

City

Postcode

Please Note

A home telephone number or a mobile number is required so that we can communicate with you.

Primary Contact Number*

Secondary Contact Number

Ethnicity*

Religion*

Please select your GP surgery below and click on the Lookup Postcode button. If your GP surgery is not listed, please select Other.

Your GP*

You have selected your GP Surgery as Other. Please enter your GP surgery details manually.

GP Address*

City*

Postcode*

Is your GP aware of your caring role?*

Yes

If No, could you explain why this is the case

Language and Communications

We want to find out a bit more about the best way of communicating with you. The more we know the easier it is.

What is your preferred language

Do you need an interpreter?

Yes

Please give details of any interpreter requirements needed*

Do you have any special communication needs?*

Yes

Please give details of any special communications requirements needed

What is your preferred method of communication?*

Home Telephone

Mobile Phone

Are you, or the person you care for, a current serving member of the armed forces or an armed forces veteran?*

Yes

Please provide details*

Please Note:

You have selected Email as your preferred communication method but have not entered an Email address for us to contact you.

The Person You Care For

Now we are going to ask you some questions about the person you care for. This is so that we can get a good idea of the care you are offering and can make sure that your carers action plan fits you as well as it can.

How many hours of care do you provide per week?*

How many people do you care for:*

Do you care for anybody under the age of 18?

Yes

Please give further details

Name of Person Being Cared For*

Title First Last

Do you live with the Person Being Cared For?*

Yes

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

Person Being Cared For's Address*

City

Postcode

Person Being Cared For's Gender*

Person Being Cared For's Date of Birth

DD slash MM slash YYYY

Person Being Cared For's Ethnicity*

Person Being Cared For's Religion*

Please select their GP surgery below and click on the Lookup Postcode button. If their GP surgery is not listed, please select Other.

Person Being Cared For's GP*

You have selected their GP Surgery as Other. Please enter their GP surgery details manually.

GP Address

City

Postcode

What is your relationship to the person being cared for?*

How long have you been caring for them?*

What condition is the person being cared for affected by?*

If Other, please state the condition affecting the person being cared for*

Please give details of the peron being cared for's condition/diagnosis

Is the person being cared for receiving support for their receiving support for their condition/diagnosis?

Yes

If Yes, please give details

Name of Person Being Cared For #2*

Title First Last

Do you live with the Person Being Cared For #2?*

Yes

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

Person Being Cared For #2's Address*

City

Postcode

Person Being Cared For #2's Gender*

Person Being Cared For #2's Date of Birth

DD slash MM slash YYYY

Person Being Cared For #2's Ethnicity*

Person Being Cared For #2's Religion*

Please select their GP surgery below and click on the Lookup Postcode button. If their GP surgery is not listed, please select Other.

Person Being Cared For #2's GP*

You have selected their GP Surgery as Other. Please enter their GP surgery details manually.

GP Address*

City*

Postcode*

What is your relationship to the person being cared for #2?*

How long have you been caring for them #2?*

What condition is the person being cared for #2 affected by?*

If Other, please state the condition affecting the person being cared for #2*

Please give details of the peron being cared for #2's condition/diagnosis

Is the person being cared for #2 receiving support for their receiving support for their condition/diagnosis?

Yes

If Yes, please give details

Name of Person Being Cared For #3*

Title First Last

Do you live with the Person Being Cared For #3?*

Yes

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

Person Being Cared For #3's Address

City

Postcode

Person Being Cared For #3's Gender*

Person Being Cared For #3's Date of Birth*

DD slash MM slash YYYY

Person Being Cared For #3's Ethnicity*

Person Being Cared For #3's Religion*

Please select their GP surgery below and click on the Lookup Postcode button. If their GP surgery is not listed, please select Other.

Person Being Cared For #3's GP*

You have selected their GP Surgery as Other. Please enter their GP surgery details manually.

GP Address*

City*

Postcode*

What is your relationship to the person being cared for #3?*

How long have you been caring for them #3?*

What condition is the person you care for #3 affected by?*

If Other, please state the condition affecting the person you care for #3*

Please give details of the peron being cared for #3's condition/diagnosis

Is the person being cared for receiving support for their condition / diagnosis?

Yes

If Yes, please give details

Your Caring Role

Now we are going to ask you some questions about the support you provide to the person you care for.

On a scale of 1 to 5 how much does your caring role impact your every day life?

1	2	3	4	5

1 being minimal impact - 5 being maximum impact

You have indicated the person(s) being cared for has a learning disability. Would you like us to put you in touch with Barnet Mencap?*

Yes

You have indicated the person(s) being cared for has mental health issue. Would you like us to put you in touch with Mind in Enfield and Barnet?*

Yes

You have indicated the person(s) being cared for has dementia. Would you like us to put you in touch with Dementia Club UK?*

Yes

You have indicated the person(s) being cared for has cancer Would you like us to put you in touch with Cherry Hill Lodge?*

Yes

You have indicated the person(s) being cared for is frail through aging. Would you like us to put you in touch with Age UK Barnet?*

Yes

You have indicated the person(s) being cared for is frail through aging. Would you like for one of our homecare team to complete a Falls Risk Assessment?*

Yes

We need to know if you have any concerns about your personal safety when carrying out your caring responsibilities. Remember, this assessment is confidential. However, if you tell us that you do not feel safe, we can help you by sending a Safeguarding alert to your local authority.

Does the person you care for present any challenging behaviour as a result of their condition? (I.e. outbursts such as shouting, hitting, throwing objects; or self-harm)*

Yes

Not that I am aware of

If Yes, could you give details of the kind of situation where the challenging behaviours may occur

Does the person(s) being cared for take any medication to control their challenging behaviours?*

Yes

Is this medication reviewed regularly by the person(s) being cared for's GP?*

Yes

Do you feel calm knowing that the person(s) being cared for will not harm themselves or yourself?*

Yes

Most of the time

If so, could you give details of what support or training you may benefit from receiving

Has the person(s) being cared for ever been physically or verbally aggressive?*

Yes

If the person(s) being cared for ever been physically or verbally aggressive, please could you give some details

Do you feel your caring role puts you in a position where you could be at risk of injury? I.e. physically demanding due to lifting, dealing with physical outbursts from the person you care for*

Yes

If you are afraid of injuring yourself, please could you give some details

What type of care you provide? Select as many as applied.*

Personal care (help to go to the toilet)

Personal care (help with washing, bathing, showering, getting dressed)

Personal care (help with feeding)

Dealing with behavioural escalations

Managing/administering medication

Help liaising with professionals (completing forms, appointments)

Help with managing finances / paying bills

Household tasks (cooking, cleaning, laundry, food shopping)

Help with communication

Help with transportation

Emotional support

Please give us more details if you would like to

Do you receive help from any of the following sources?*

Adult Social Care (Social Services)

Paid carers

Other charitable organisations

Respite care

Family or friends

Religious community

GP or other health practitioner

Cared for person attended a day centre

I don't receive any help

Other

If Other, please could you give details from whom you receive additional support

Respite care is taking a break from your caring responsibilities while the person you care for is looked after by someone else. This is time for you to perhaps take a rest, enjoy hobbies, see friends (not time to attend your medical/hospital appointments).

Please provide further details*

Do you require any extra help?*

Yes

If you need extra help, what do you need help with?*

Are you able or willing to continue caring in your caring role?*

Yes

Yes, but with support

If you need extra help, what do you need help with?*

Emergency Plans

If you do not have any plans in place, you can complete a Carers Emergency Plan.

Are there plans in place if you are taken ill or temporarily unable to carry on supporting the person(s) being cared for?*

Yes

Not Sure

If Yes, please give details*

Do you feel you would benefit from being put in touch with our specialist Homecare team who may be able to provide extra support for you and the person(s) being cared for?

Yes

Would you like to sign up for the Local Authority's Emergency Card Scheme should you be taken ill?

Yes

What support do you receive relating to this?

Your Wellbeing

Please tell us about how your caring role affects your general health and wellbeing. For example, you may want to tell us if you have any concerns about your health, if you have any diagnosis / registered disability, if your caring role interferes with your sleep, affects your mood or how you feel, or causes you any physical pain or strain.

Have you got any health issues?*

Yes

If Yes, please give details*

On a scale of 1 to 5 how much does your caring role impact your health and wellbeing?

1	2	3	4	5

1 being minimal impact - 5 being maximum impact

Please give details around any diagnosis and the impact that this has*

Does your caring role involve manual handling?*

All the time

Occasionally

Never

e.g. lifting somebody out of bed; helping them transfer out of their wheelchair

Do you feel you would benefit from receiving training with regards to manual handling?*

Yes

Maybe

Does your caring role affect your daily meal routine?*

Yes

If Yes, please give details

Anxiety Related to Your Caring Role

We would like to understand any issues that you may be experiencing related to your caring role.

For example, have you been unable to stop or control worrying, been unable to relax, feeling easily annoyed or irritable, had difficulty controlling thoughts or emotions, feeling unable to sit still due to feeling restless, feeling afraid or unsure of the future.

On a scale of 1 to 5 how much does your caring role impact on your emotional and mental health?

1	2	3	4	5

1 being minimal impact - 5 being maximum impact

Do you currently or have you in the past received any mental health support eg self-help, talking therapies, counselling, medication, support worker.

Your Family and Personal Relationships

Does your caring role prevent you from spending time with friends and other members of your family?*

Yes

How does this impact your friendships and family relationships?*

Do you feel you can talk to family and friends about your caring role and how it affects you?

Yes

Is there anything else you would like to say about your Family and Personal Relationships?

Hobbies and Interests

On a scale of 1 to 5 how much does your caring role impact finding time for yourself?

1	2	3	4	5

1 being minimal impact - 5 being maximum impact

Please give details on the impact it is having*

What do you need help with in getting time away from your caring role? Tick the ones that apply.*

Accessing a break from my caring role

More support for the person I care for, so I can have more time for myself

Engage in activities from Barnet Carers

Engage in activities from other Charitable Organisations

I want a Leisure Pass to get discount at the gym

Information about Carers Smart Card

I don't require any help at present

Other

If Other, please give details*

When you are not involved with your caring duties, what activities do you enjoy doing?*

Home Environment

Please tell us if your caring role is preventing you from maintaining your household tasks.

On a scale of 1 to 5 how much does your caring role impact managing home related tasks?

1	2	3	4	5

1 being minimal impact - 5 being maximum impact

Please give details on the impact it is having*

What help do you receive? Tick the ones that apply.*

Other family members help with the cleaning

Other family members do the cooking

Other family members deal with paying the bills

Other family members help with shopping

Friends and/or neighbours help with shopping

I do online shopping

I have a private cleaner

I don't receive any help

Other

If Other, please give details*

What do you need help with? Tick the ones that apply.

Cleaning

Cooking

Form filling

Shopping

To book support, please click on the Form Filling Booking Page

Is there anything else you would like to say about your Home Environment?

Paid Work, Training and Volunteering

In terms of employment are you:

Full time

Part time

Student

Unemployed

Full time carer

Retired

Would you like to seek employment?

Yes

On a scale of 1-5 how much is your caring role impacting on your financial situation*

1	2	3	4	5

1 being minimal impact - 5 being maximum impact

Which of these benefits are you receiving?

Carer's Allowance

Personal Independence Payment (PIP)

Attendance Allowance

Employment and Support Allowance (ESA)

Job Seeker's Allowance (JSA)

Income Support

Housing Benefit

Child Benefit

Universal Credit

Other

If Other, please give details*

Would you like support/ information in relation to:

Benefits

Debt

Employment

This field is hidden when viewing the form

What Do You Need Help With?

You have indicated that you would like help with the following areas:

Barnet Leisure Pass
Click on the above link to receive your carer confirmation which entitles you to a Barnet Leisure Pass at Better Gyms.

CarerSmart Card
Click on the above link to find out more information and register for your CarerSmart Card allowing you to access discounts from numerous retailers.

Touchpoint
Click on the above link to access the self-referral form to talk to a Benefits Advisor.

Form Checking Service
Click on the above link to access the booking page for our form checking service.

Barnet Carers Emergency Card Factsheet
Click on the above link to download information relating to the Emergency Card scheme.

Barnet Carers Emergency Card Registration
Click on the above link to access the Emergency Card Scheme Registration Form.

Please contact me to discuss my caring role*

Yes

The Online Carers Assessment is now complete

Once you have agreed with our Privacy Policy and clicked Submit, your completed assessment will be sent to our Carers Service team who will be in touch with you shortly.

Consent*

I agree to Privacy Policy.

Assessor's Comments

Global House
303 Ballards Lane
London N12 8NP

Open Hours

Mon–Fri, 9am to 5pm,
Our office is currently closed to visitors except on appointment

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Barnet Carers is a registered charity. Charity No. 1057539

Social Prescriber Referral

Online Carers Self Assessment PQQ

Personal Information and Contact Details

Please Note

Language and Communications

Please Note:

The Person You Care For

Your Caring Role

Emergency Plans

Your Wellbeing

Anxiety Related to Your Caring Role

Your Family and Personal Relationships

Hobbies and Interests

Home Environment

Paid Work, Training and Volunteering

What Do You Need Help With?

The Online Carers Assessment is now complete

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