After the last question click submit and we will contact you via phone or email.

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* 1. Do you live with the person you care for?

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* 2. Are you self-isolating as per the government guidance?

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* 3. Are you a key worker who is still going into the workplace (not working from home)?

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* 4. How old are you?

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* 5. Do you have a health condition that places you in the group of people who have been instructed to self isolate for 12 weeks?

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* 6. Are you currently experiencing any covid 19/coronavirus symptoms yourself?

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* 7. Is the person you care for self-isolating as per government guidance?

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* 8. How old is the person you care for?

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* 9. Does the person you care for have a health condition that places them in the group of people who have to self isolate for 12 weeks?

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* 10. Is the person you care for currently experiencing any covid-19 / coronavirus symptoms?

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* 11. If either you or the person you care for are experiencing covid-19 / coronavirus have you called 111 for information and advice?

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* 12. If you become ill is there someone else who can care for the person you currently care for until you recover?

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* 13. Do you or the person you care for need support with any of the following? (Please tick all that apply and type anything else you need support with in the "other" box)

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* 14. Would you like a member of the WIRED carers support team to give you a call back to see how we can support you?

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* 15. Please type your full name in the box below.

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* 16. Please type your phone number in the box below.

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* 17. Please type your email address in the box below.

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