Support for Carer form

A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support'.

The assessment is an opportunity to discuss your needs as a carer and identify available support. This form is designed for you to apply for a Carers Assessment.

The information you submit in this form could be passed to Citizens Advice Mid Mercia, who will contact you regarding the Carers Conversation. This may involve linking with other organisations to ensure the best possible outcome for you.

More information about can be found on the Carer's Support page.


The fields marked with an asterisk (*) are required fields. All the information you enter will be submitted securely.

Section 1 of 2 - Your details as the carer

* Your name:
* Your address:
* Your date of birth (dd/mm/yyyy)
* Your contact telephone number:

Section 2 of 2 - Details of the person being cared for

* Name of the person being cared for:
* Date of birth of the person being cared for (dd/mm/yyyy)
* Your relationship of the carer to the person being cared for:
* If the person being cared for lives at a different address to the carer,
please give their address here:

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