FORM - Parent Carer Self assesment form

Parent Carer's Trauma Informed Self-Assement

Please feel free to use this form to record the support you may benefit from in your role as a Parent Carer. You may skips questions or just provide brief answers.

Remember your lived experience is valid evidence

About You

Your Surname

Your First name

Phone Number

Preferred Contact method Required

Phone

Who do you care for?

Their Name (first & Last)

Their Age

Relationship

Their Diagnosis or Additional needs

Your Caring Role

In your own words, what does your cring role involve?

What part of caring take the most energy right now?

Impact on Your Health and Wellbeing

Physical Health Impact

Emotional or mental wellbeing impact

Any past experiences with services that still affect you

Daily Life and Sustainability

Impact on work, study or finances

impact on relationships

Times when caring feels close to breaking point

Breaks and Support

Current breaks from caring

Practical support needed

What meaningful respite woul look like for you

What helps and What harms

What helps you cope

Support that has helped before

Support that caused harm or distress

What would make the biggest difference

Practical support needed

Emotional or theraputic support needed

Support to feel safer about the future

Final Reflections

Anything else decision-makers need to understand