Please enable JavaScript in your browser to complete this form.

- Step 1 of 10

Carers Emergency Plan

If you would like help to complete this form please contact Carers Link on 0800 975 2131 or email enquiry@carerslink.org.uk.

Date of plan

1. Personal details

Carers details

Name *

Address *

Town

Postcode *

Email address *

Main contact number

Alternative contact number

Date of birth (or age)

Gender

Your relationship to the person you care for *

Do you live with the person you care for?

Power of Attorney (POA) and/ or Guardianship may allow you to make decisions on behalf of the person you care for. This can include care arrangements and/ or financial arrangements. If you'd like further information about this please contact Carers Link

Is POA in place for the person you care for? *

Names of all who hold POA

Please state if this is a welfare POA or a continuing POA, or both

Welfare
Continuing

Is Guardianship in place for the person you care for? *

Who holds Guardianship?

Please state if this is welfare or financial/ property, or both

Welfare
Financial/ property

Cared for person's information

Name *

Likes to be called

Address *

Town

Postcode *

Telephone number

Date of birth (or age)

Gender

Preferred language

What is the cared for person's specific condition?

Does the cared for person have religious/ spiritual requirements that are important to them?

Does the cared for person have any favourite people they can relate to?

Are there any personality traits that should be considered?

Could the cared for person safely remain at this address?

How long could they remain at this address without your support? Hours? days?

Who holds keys for access to this property?

Is the cared for person known to social work? If yes, please provide contact details.

2. Emergency contacts.

Primary emergency contact

Name *

Address *

Town

Postcode *

Main contact number *

Alternative contact number

Relationship/ organisation they are involved with *

Is this person a key holder? *

Does this person know about the cared for person's medication?

How can this person help in an emergency?

Please tick the box below to indicate that the emergency contact agrees to be contacted. *

Date

Secondary Emergency contact

Name

Address

Town

Postcode

Main contact number

Alternative contact number

Relationship/ organisation they are involved with

Is this person a key holder?

Does this person know about the cared for person's medication?

Please tick the box below to indicate that the emergency contact agress to be contacted

Date

3. Medical & general information

should What What

Carer's GP

Name of carer's GP

Practice name & address

Practice contact number

Cared for person's GP

Name of cared for person's GP

Practice name & address

Practice contact number

Cared for person's usual pharmacy

Pharmacy name and address

Pharmacy contact number

Medical information

Does the cared for person have any other long term/ chronic conditions such as asthma, diabetes etc.?

Does the cared for person have any known allergies (anything that might require medical attention)?

Does the cared for person have difficulty communicating?

Cared for people often maintain that they can cope alone. If questioned, can the cared for person's replies generally be relied upon?

Cared for person's medication

Is a dosette box prepared?

Where can the medication be found?

Are there any specific issues about medication e.g. timings etc.?

Are there any issues around taking medication?

4. Carers Link Emergency plan, details of a typical daily plan for:

Name *

To help the person providing replacement care, list the things you do every day for the person you care for, starting from first thing in the morning. Please detail all the help and support you receive, including health, social work and private services.

Does the person you care for need any assistance during a typical day?

A typical day