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Application for Carer's Grant

 

NAME OF CARER

Carer's email:  

Age Group: 18-64 65-74 75-84 Over 85

NAME OF THE PERSON CARED FOR

Age Group: Under 18 18-64 64-75 Over 85

ADDRESS FOR COMMUNICATION:

DAYTIME TELEPHONE NUMBER:

EVENING TELEPHONE NUMBER:

NUMBER OF CARE HOURS PROVIDED BY THE CARER OVER

A WEEK (APPROX.)

THE REASON CARE IS BEING PROVIDED (Please give full details):

PLEASE GIVE A BRIEF DESCRIPTION OF THE CARE YOU PROVIDE:

DO YOU BELONG TO ANY LOCAL SUPPORT GROUPS?

(Please Name)

DO YOU REGULARLY RECEIVE ANY BREAKS?

YES NO

IF SO, FROM WHOM? (Please give full details)

DO YOU REQUIRE CARE HOURS OR A COMPLETE BREAK?

IF YOU WOULD LIKE HOURS, PLEASE STATE NUMBER OF HOURS PER WEEK AND DAYS / TIMES WHEN YOU WOULD LIKE THESE TO BE TAKEN

IF YOU WOULD LIKE A COMPLETE BREAK WHEN WOULD YOU LIKE TO HAVE THE BREAK?

WHO DO YOU WISH TO PROVIDE THE BREAK?

WHAT ARE THE TOTAL COSTS OF THE BREAK?

HAVE YOU GOT A CARE MANAGER, SOCIAL WORKER, OR OTHER? WHICH? IF SO, PLEASE GIVE A NAME AND TELEPHONE NUMBER

DO YOU NEED TO GIVE PERMISSION FOR US TO TALK TO THIS PERSON REGARDING THIS APPLICATION?

YES NO

PLEASE ADD ANY ADDITIONAL INFORMATION IN SUPPORT OF YOUR APPLICATION