Carers Wellbeing Check

We work in partnership with Birmingham Carers Hub and we need to ensure our wellbeing services are making a difference. Please complete the Wellbeing Check as fully as you can. You’ll be asked to complete this online form at regular intervals

Your Details

First Name * Last Name * Email Address * Telephone Number * Postcode * Age of the cared for: * 18 or overUnder 18 Date of Wellbeing Check: * Is this Wellbeing Check: * The first assessmentfollow up assessment

1. Your Health and Wellbeing

How often does your caring role affect your physical, mental and/or emotional health and well-being? AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

2. Work, Education and Training

Does your caring role affect your ability to work, access education or training? AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

3. Your Financial Situation

Do you have financial concerns? This includes ability to pay the bills, shopping and other expenses. AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

4. Time Out

Does your caring role affect your ability to do the things you value and enjoy such as a social life, go to leisure, religious and cultural activities? AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

5. Other caring and family commitments

Does your caring role affect your ability to care for other family members? This could be children and/or adults. AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

6. Relationships

Does your caring role affect your role and/or relationship with friends and family? For example, as a partner, father/mother, brother/sister, with others AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

7. Your Home

How often does your caring role affect your ability to keep your own home clean and safe? AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

8. Your Diet

Does your caring role affect your ability to maintain a balanced diet and eat and drink regularly and well? AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

9. How Safe do you Feel?

Does your caring role affect your own personal safety? AlwaysOftenSometimesRarelyNever Please explain why and what support/action is needed

Additional Notes and Actions

Any additional notes or actions needed If this is a follow up wellbeing check, please explain what difference this service has made to you If you were no longer able to receive our wellbeing service, what impact would it have? Based upon this service, how likely are you to recommend our service to friends or family, if they needed similar help? Extremely unlikelyUnlikelyNeither unlikely or likelyLikelyExtremely likelyDon’t know

All uses of personal data are controlled by the Data Protection Act (amended by the General Data Protection Regulations GDPR). Please see the Council and Birmingham Carers Hub website for their privacy statements www.birmingham.gov.uk/privacy and http://forwardcarers.org.uk/privacy-policy/

Carer Consent Statement

I understand that I am giving my personal information to Birmingham Carers Hub, on behalf of Birmingham City Council and other professional agencies you are working with; and you will keep it safe and only use it to assess my needs and help plan my care support. I understand that I can take away my consent at any time. I understand that without consent, this will make it difficult to assess my needs and arrange the support I need.

I am aware that I can say if there is any particular organisation that I do not want to see my information, and you will not share it with my relatives or friends without my knowledge or agreement. I understand that there may be exceptional circumstances where the law says Birmingham Carers Hub must show/share this assessment with someone else. The information I give is true and accurate and I understand that action maybe taken against me, if I have given false information.

Agree

How To Find Us

7 High Street
Harborne
Birmingham
B17 9NT
T: 0121 426 2633
E: hello@barefootharborne.co.uk

Barefoot Yoga Harborne Ltd. Company number 12553712

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