I would like some support

How did you find out about Gateshead Carers? (required)

What’s your name? (First Name) (required)

What’s your surname? (required)

Are you a carer? (required)

YesNo

If we tried to call you, what would be the best number to contact you on? (Telephone/Mobile Number) (required)

If we called you on your preferred number and you did not answer the phone, would it be okay if we left a voicemail message? (required)

YesNo

If you’ve got an email address, please type it into the box below. (Email Address)

If we were to contact you, what method would you prefer? (required)

Telephone/MobileEmail

What is the number of your house and the name of your street? (Address) (required)

What is your postcode? (Postcode) (required)

What is the name of the town you currently live in? (e.g. Gateshead, Newcastle)

What is your gender identity? (Male, Female, etc.)

What is your Date of Birth? (required)

Are you currently employed? (required)

YesNoRetired

Has your caring role affected your employment? (required)

YesNo

If your caring role HAS affected your employment. How has it affected it?

What GP surgery are you registered with? (required)

Does your GP know that you are a carer? (required)

YesNoDon’t Know

What is the main language you speak? (required)

Would you require an interpreter to have conversation with us? (required)

YesNo

Which of these best describes your ethnicity? (required)

What is your religion? (required)

What is your Sexual Orientation (required)

Do you have a disability? (required)

YesNo

If you do have a disability, please describe what disability you have.

Are you currently accessing mental health services? (required)

Yes - provided by the NHSYes - provided by voluntary sector organisationsNo

What is the full name of the person you care for? (E.g. John Smith) (required)

What is their relationship to you? (e.g. They are my Grandparent) (required)

Does the person you care for live with you? (required)

YesNo

If the person you care for does NOT live with you, please tell us their address and postcode

What is their Date of Birth? (required)

What is their Gender Identity? (required)

What main disability do they have? (required)

How many hours per week do you spend caring for them? (required)

If you care for multiple people, please use the space below to tell us the relevant details about the people you care for.

Tell us a little bit about what you’d like some support with. (required)

Please fully read and tick the following boxes if you give Gateshead Carers consent. (required)

I consent to having the details I have given on this form to be held securely on the Gateshead Carers database.I consent to Gateshead Carers retaining personal details and copies of documents related to my support for as long as it remains relevant to the support I receive.I consent to Gateshead Carers contacting me by phone.I understand that my preferred method of communication will be used as the main way of keeping me updated and sending out the regular e-newsletter and events calendar. I consent to my contact details being used in this way. I understand that my information will not be shared outside of the organisation without my knowledge or consent. Except in circumstances of safeguarding where it is necessary to ensure the safety of those involved. I understand that I can remove my consent at any time and my personal details will be removed from the Gateshead Carers database except if legally required to do so. i.e because it is required under financial regulations if you have been paid a grant.I understand that I can ask to see my personal details held by Gateshead Carers at any time.

I would like some support

About You

About the person you care for

Consent