Carers Self Assessment Form

The information in this form is to help you and your social care coordinator work out what your needs are in relation to your caring role, and what outcomes you would like to achieve by having support. You may also have other needs not listed, and we also need to know about these to help support you. The information contained in this form will help start a discussion and give a picture of what your needs are.

If you feel that you are in crisis and are unable to continue with your caring role, please do not attempt to complete this form, call Access and Information on 01628 683 744 for help.

If you would like some support to complete this form, please contact Access and Information for support on 01628 683 744.

Please complete all sections

Download the form here - please return the form to, or use the online form below to submit your copy. 

Please note that Optalis will treat your information confidentially. Visit our privacy statement page for more information.

Max size: 2048kb - PDF, Word or Text files only.

The form is divided into four parts:

  • Part A: Some background information about you
  • Part B: Twelve questions designed to provide information about how your role impacts on the outcomes the Care Act (2014) lists under the Carers’ eligibility criteria for social care support
  • Part C: A jointly agreed assessment of your needs, and a jointly developed plan of support
  • Part D: A section for a member of staff to summarise the eligibility criteria information.

The information can be completed by you, with anyone you would like to help you, and with your social care coordinator when they come to see you. We are sending this to you now so you can start having a think about the sorts of things you need support with.

Before all of this is discussed with the coordinator, they will check with you when you understand why all this information about you is being discussed and recorded, whether you agree to this (“give consent”), and whether you agree for information about you to be shared with other people who may need to know for the purpose of providing care and support, and keeping you independent and well.

In July 2014, the Government passed the Care Act which listed the criteria for carers being eligible for social care support. The outcomes listed in the Act that the Local Authority needs to make sure carers can achieve are:

  • Carrying out any caring responsibility the care has for a child
  • Providing care to other persons for whom the carer provides care
  • Maintaining a habitable home environment (keeping the home clean, tidy and safe)
  • Managing and maintaining nutrition (eating and drinking properly)
  • Developing and maintaining family or significant personal relationships
  • Engaging in work, training, education or volunteering
  • Making use of necessary facilities or services in the local community
  • Engaging in recreational activities

If the difficulties achieving these outcomes are because of necessary caring responsibilities, which are having a significant impact on the wellbeing of the carer, then the carer may be eligible for support from Adult Social Care.

“Necessary” care means the care that somebody needs because they are unable to do crucial things for themselves, but not because they choose not to, or the carers chooses to do them. This is quite a difficult distinction, and practitioners must discuss this with carers as part of the assessment.

Wellbeing is a broad concept and is described in the Act as relating to the following areas in particular:

  • Personal dignity (including being treated with respect)
  • Physical and mental health and emotional wellbeing
  • Protection from abuse and neglect
  • Control over day-to-day life (including over care and support provided, and the way it is provided)
  • Participation in work, education, training or recreation
  • Social and economic wellbeing
  • Domestic, family and personal domains
  • Suitability of the individual’s living accommodation
  • The individual’s contribution to society.

Whether not being able to achieve an outcome has a significant impact will vary from person to person. For example, not being able to participate in recreational activities may be a significant problem for one person, but another person may feel that is not so important. It is all about what is most important to you, and possibly the accumulation of low level impact.