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Call us: 01670 320025

info@carersnorthumberland.org.uk

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Our Services
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Registration

Home
Registration

Your Details

Title

Surname

First name

Your Address

Address 1

Address 2

Town

County

Post Code

Contact Telephone Number

Mobile Number

Email Address

Are you a?

Further Details

How many hours a week do you spend caring?

Gender

Male
Female
Unspecified

Date of Birth

Equality Monitoring

All information will be held anonymously, and will only be used to inform funders and other stakeholders of the reach of our services.

Ethnic Origin

Religion or Belief

Economic Status

GP Surgery

Does your GP know you are a carer

Yes
No

Sexual Orientation

Carer Group Please select which applies to you...

How did you find out about Carers Northumberland?

What made you register with us today?

Is there anything you would like help with right now or do you have a question? Please leave comments in the below box and a member of the team will contact you.

About the person you care for...

Gender

Surname

Date of Birth

Main disability

Post code The first section only i.e. NE63

Are you

Primary carer
Secondary carer

What is their relationship to you?

Consents

I understand by completing this form I consent to the details I To be registered with Carers Northumberland we need to hold information about you on our secure database, this information is not shared without your consent to any other outside organisation or person ( except where we are legally required to do so, for example in safeguarding situations) Your information will be stored for up to six years after your contact with Carers Northumberland has ended, after which time it will be securely destroyed. * If you would like to know more about how we store and use your data you can request a copy of our privacy statement by emailing: info@carersnorthumberland.org.uk or calling 01670 320025. Please note by selecting no, we cannot continue with your application.

Yes
No

I consent to Carers Northumberland contacting me by phone *

Yes
No

I understand that my email address will be used as the main way of keeping me updated and sending out the monthly e-newsletter. I consent to my email being used in this way *

Yes
No

I understand that I can remove permissions for contact at any time by contacting Carers Northumberland directly. *

Yes
No

How do you feel?

Finances-Benefits; debts; managing money; legal issues

Health -Managing physical & mental health: healthy lifestyle; doctors & other health

How you feel-Feeling supported; dealing with anxiety or stress; managing and difficulties in a key relationship

Managing at home-Day-today tasks and the suitability of your home – or that of the person you care for if you don’t live with them.

The caring role-Skills; understanding; practical caring; legal issues; planning ahead; communicating with professionals

Time for yourself -Social life; activities; breaks from hands-on caring

Work-If you’re retired or a full-time carer there’s no need to do this scale– simply place yourself at 5 to complete your baseline star.

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Address

107 & 109 Station Road
,
Ashington
,
Northumberland
,
NE63 8RS

info@carersnorthumberland.org.uk

01670 320025

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Email Address *

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