Info regarding the person you are referring Carers Consent obtained (Please select) Yes No
Name
Date of Birth
Gender (Please select) Male Female Non-binary Transgender Other
Gender (Other)
Ethnicity (Please select) White Mixed or Multiple ethnic groups Asian, Asian Scottish or Asian British African, Caribbean or Black Other Ethnic Background Prefer not to say
Home Address
Postcode
Social Locality (Local Health/GP centre)
Phone Number
Email Address
Type of care given: (help with personal care, help with shopping, domestic tasks, etc)
For how long have they been providing care for this person? (Please select) Less than one year One year but less than five years Five years but less than ten years Ten years but less than 20 years 20 years or more
How many hours a day do they provide care?
On average, how many hours a week do they spend caring or providing support? (Please select) Up to four hours five to 19 hours 20 – 34 hours 35 – 49 hours 50+ hours
Anything else you want to tell us in relation to this?
Information About Person Being Cared For This section relates to the CARED FOR PERSON. Please choose the correct statement which applies:
Please provide the following information about the CARED FOR PERSON:
**As a minimum, we require the NAME of the cared for person**
Does the cared for person live with them? (Please select) Yes No
Name
Gender (Please select) Male Female Non-binary Transgender Other
Gender (Other)
Ethnicity (Please select) White Mixed or Multiple ethnic groups Asian, Asian Scottish or Asian British African, Caribbean or Black Other Ethnic Background Prefer not to say
What is their relationship to the person they care for? (Please select) They are the child/grandchild of the cared for person They are the parent/grandparent of the cared for person They are the spouse/partner of the cared for person They are a relative (any other relationship) of the cared for person They are a friend/neighbour of the cared for person
What is the illness/condition/disability of the person they care for? Please choose all that apply.
Illness/condition/disability (Other)
Is their caring role impacting on them? (Please select) None Some Lots
If you indicated some or lots above, please detail how you consider their caring role has impacted on them. Please choose all that apply.
Impact (Other)
Referring professional Name
Agency
Phone Number
Email Address
Data Protection Shetland Carers have a legal requirement to submit a Carers Census Return to Scottish Government on an annual basis. All data provided is anonymised. The information which we request in this form is in line with this.
Here at Shetland Carers/Voluntary Action Shetland (VAS) we take your privacy seriously and will only use your personal information to administer your account through our database, to provide the products and services you have requested from us and from time to time to share information relating to the service we provide. In order to provide carers with a better service we are now working in partnership with Shetland Care Attendant Scheme (SCAS) where we will share your information with this organisation via a joint database. If you have any concerns about this please discuss this with us.
Where appropriate, and with your consent, we will liaise with a range of other partners to support you in your caring role.
Please indicate your preferred method(s) of communication:
Throughout the year we would like to send you our quarterly newsletter to provide information relating to our service. Please tick if you agree to us providing you with a copy of our newsletter. You can unsubscribe from receiving our newsletter at any time.
Shetland Carers aligns with the Shetland Child and Adult Protection Procedures and we may need to pass on information where it is deemed necessary to do so.
I HAVE READ THE INFORMATION ABOVE AND I CAN CONFIRM THE DETAILS ARE CORRECT.
Agree & Send
