Carer Alert Scheme Form

Your Details:

Your Name: (*Required field)  

Your Date of Birth: (*Required field)  

Your Address: (*Required field)  

Your Postcode: (*Required field)  

Your Home Telephone Number:  

Your Work Telephone Number:  

Your Mobile Telephone Number:  

Email: (*Required field)  

Details of the person you care for:

Name: (*Required field)  

Date of Birth: (*Required field)  

Address: (*Required field)  

Postcode: (*Required field)  

Home Telephone Number:  

Work Telephone Number:  

Mobile Telephone Number:  

GP Name: (*Required field)  

GP Practice: (*Required field)  

GP Telephone Number: (*Required field)  

What is the relationship to you of the person being cared for? (eg. son, mother, etc.) (*Required field)  

What is his/her illness or disability? (Please list all conditions, such as "Diabetes - tablet controlled"/"dementia"/"deaf or hard of hearing", etc.)  

Nominated People

If yes, please put their details in the nominated person box/es below. They must have access to the property and be able to fill in or know what to do in an emergency. A basic “Plan of Care” is available for the carer and nominated person/people to fill in and keep handy.

• Would you like be sent the Plan of Care?

Number of copies:  

Nomated Person 1 - First Contact

Person 1 Name: (*Required field)  

Person 1 Address: (*Required field)  

Person 1 Postcode: (*Required field)  

Person 1 Email:  

Person 1 Home Telephone Number: (*Required field)  

Person 1 Work Telephone Number:  

Person 1 Mobile Telephone Number:  

Person 1's Relationship to the person being cared for: (*Required field)  

Nominated Person 2 - Second Contact

Person 2 Name:  

Person 2 Address:  

Person 2 Postcode:  

Person 2 Email:  

Person 2 Home Telephone Number:  

Person 2 Work Telephone Number:  

Person 2 Mobile Telephone Number:  

Person 2's Relationship the to person being cared for:  

What if there is no nominated person?

If there is no nominated person or the nominated person / people are not available, we will automatically call social services to make emergency arrangements.

If yes, please tell us which worker / team:  

Information to share with the emergency services

What does the person you care for need help with? (Please select all the relevant options)

Please tell us more including dietary, cultural or religious needs:  

Emergency Services

How would the emergency services get in, is there a spare key? Please describe who has it and how to get hold of them/where it is kept or how it can be accessed  

Other Support

Please tell us about any services already in place e.g. home/daycare?  

Name (of person or service):  

What they do:  

When they visit/services take place:  

Contact number:  

If more than one service is received please give us full details of the others:  

Other Information

Please tell us anything else that may be useful for people to be told, including whether you have a pet and what you want us to do with it  

Completed by

Name: (*Required field)  

Telephone Number: (*Required field)  

Email Address: (*Required field)