Carers Questionnaire

If you are a carer then please inform your surgery by completing this questionnaire. Your surgery will use this information in order to keep their records up to date.
1. Do you care for someone for more than 10 hours per week?	Yes No
2. How long have you been caring for this person?
3. Have you received any information about the support you could get as a carer?	Yes No
4. Can your details be passed onto your local Carers Development Worker, who will be able to send you up to date information and provide support?	Yes No
5. What is your relationship to the person you care for?
6. Please provide the following contact information
Name:
Title:
Street Address:
Address (cont.):
City:
County:
Postal Code:
Daytime Phone:
Evening Phone:
E-mail:
7. Please indicate if you are a Carer or are sending this on behalf of someone who is a Carer and you feel they are in need of information or support:	I am a Carer I am filling this in on behalf of a Carer

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