Card Registration Service – Slough Carers Support

Carers Card Registration

Carers Card Number

First Name

Last Name

Email

Postcode

Name of Your Doctors Surgery

Mobile Phone Number

Approximately When Did You Start Caring

Age of the Person you Care For

Adult

Child Under 18

Register For Slough Carers Support Newsletter

Yes

No

Tier 1 Conversation

Source of Registration

Conversation Date

Conversation Summary

Date of Birth

First line of Address

Postcode

Gender

Ethnicity

What you have told us about your caring situation

What is working well in your caring role?

Support and Information

For staff to complete

Follow up actions

Have any safeguarding issues been identified?

Safeguarding actions

Referred for a full carers assessment?

Is a young carer involved?

Yes

No

Referred to Young Carers Coordinator?

Yes

No

Person Completing this form

Organisation completing this form