DevPage | The Carers' Centre - Bath and North East Somerset

Is this child on a child protection plan? *

Yes No Unsure

Who does the child care for? *

Parent Sibling Grandparent Friend Other

Other

Do they look after more than one sibling? *

Yes No

Primary condition of parent

Childhood Disability/Additional Needs Dementia/Memory Loss Adult Learning Disability Sensory Needs Mental Health Physical Health Substance abuse/Addiction Long-term conditions Other

Primary condition of person being looked after

Primary condition of sibling

Childhood Disability/Additional Needs Child Learning Disability Adult Learning Disability Sensory Needs Mental Health Physical Health Substance abuse/Addiction Long-term conditions Other

Primary condition of second sibling

Childhood Disability/Additional Needs Child Learning Disability Adult Learning Disability Sensory Needs Mental Health Physical Health Substance abuse/Addiction Long-term conditions Other

Primary condition of grandparent

Childhood Disability/Additional Needs Dementia/Memory Loss Adult Learning Disability Sensory Needs Mental Health Physical Health Substance abuse/Addiction Long-term conditions Other

Primary condition of friend

Other

Is there another person living in the house who is also providing care? *

Yes - an adult Yes - a child No they are the sole carer

What kind of support does the child provide? *

Household Looking after siblings Emotional support Personal care Something else None

Something else

Which areas of the child life are significantly affected by their caring role? *

Education Wellbeing Health Social time Family time None

Has this child expressed that they are unhappy with their caring role? *

Yes No

Additional information

How would you like us to contact you about your child's caring role? *

Phone Email Post SMS

If we can't reach you, are we able to leave a voicemail?

Yes No

How did you hear about us?

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Data Consent *

I agree to the Carers’ Centre holding our personal information in accordance with their Privacy Policy