Name:      	Main ID:      	Main assessor:      	
Joint Carer’s Supplement – Question Set                                                                                                                                  Confidential	
Name:	     	Gender:		
Date of birth:	      	
Supporting you in your assessment	
Preferred language:	     	Do you need an interpreter?	Yes		No		
Do you consider yourself to be any of the following:	Deaf		Blind		Deafblind		
Do you have communication difficulties?	Yes		No		
Do you have any difficulties with understanding and/or retaining information?	Yes		No		
Do you have any difficulties making decisions and/or understanding their impact?	Yes		No		
If you have difficulties in communication, understanding or decision-making, you may need support for your involvement in your assessment, an advocate to represent you and help you explain your views, or a mental capacity assessment.	
Details of difficulties and what would help you communicate more easily during your assessment
(e.g. a family member or friend present, an independent advocate, specialist communication support)	
Details:      

	
About you	
Do you live with the person you care for?	Yes		No		
Your personal and family background (including important recent events or changes in your life)	
Details:      

	
What areas of your life do you most enjoy or value? (including your main interests and where you can most contribute)	
Details:      	
What changes would most improve the way you feel or your quality of life?	
Details:      

	
What parts of your caring role do you think are most important, valuable and positive?	
Details:      

	
What is the risk of your mental health getting worse due to being a carer?		
What is the risk of your physical health getting worse due to being a carer?		
Details of risks to how you are feeling: 

	
Record of completion (this section to be completed by a social care authorised person)	
Date of assessment:	     	Assessment type:	Initial		Reassessment		
Location of assessment:	     	Is this a supported self-assessment?	Yes		No		
If ‘No’, main assessor:	     	Assessor contact details:	     	
Summary of your assessment and eligibility (this section to be completed by a social care authorised person)	
The Local Authority has a duty to work with you to prepare a care and support plan when the following statements apply:
1.	Your physical or mental health is, or is at risk of, deteriorating; OR
2.	As a result of your needs you are unable to achieve one or more of the eligible outcomes below and there is likely to be a significant impact on your wellbeing.	
Outcomes	Summary of your needs in each area	
Keeping a habitable home environment in the carer’s home (whether or not this is also the home of the adult needing care)	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or anyone else?	Yes  	No   	
	Details:      	
Managing and maintaining nutrition	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Carrying out any caring responsibilities the carer has for a child	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Providing care to other people who the carer provides care for	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Developing and maintaining family or other personal relationships	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:

      	
Using necessary facilities or services in the local community (including public transport, and recreational facilities or services)	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:

     	
Taking part in recreational activities	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Taking part in work, training, education or volunteering	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Is your physical or mental health getting worse (or at risk of getting worse)?	Yes  	No   	
Are one or more areas indicated as ‘No’ above?	Yes  	No   	
Impact of your needs on how you feel	
As a result – is there, or is there likely to be, a significant impact on how you feel?	N/A  	Yes  	No   	
The impact on how you feel should be looked at disregarding any support you may already have and should take into account the following areas, as well as your (or your representative’s) views:

● Personal dignity and being treated with respect              ● Physical and mental health and emotional wellbeing
● Protection from abuse and neglect                                  ● Suitability of living accommodation
● Participation in work, education, training or recreation    ● Social and economic wellbeing
● Domestic, family and personal relationships                     ● Your contribution to society
● Control over day-to-day life (including over care and support provided and the way it is provided)	
Details of the impact on how you feel (in the absence of any help you may already have in place):     	
Information and advice	
Information and advice about your current needs	
Details:      	
Information and advice about preventing or delaying the development of needs in the future	
Details:      	
Agreement	
I / my supporter is satisfied that I and/or (s)he was involved in this assessment as much as possible and that I / my supporter was able to express what I / s(he) felt should be taken into account:	
Your signature (or signature of your supporter where relevant)	     	Date: