Wirral Carers Health and Wellbeing Service - Carers online Wellbeing Check.

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

Do not use this form for Covid Vaccinations.

If you care for someone over the age of 16years please contact the Carers Helpline on 0151 670 0777 option 1. You will need your NHS number with you to book a vaccination

If you care for someone under the age of 16 then please contact Wirral CCG on 0151 651 0011 for more information about Covid vaccinations

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

Yes

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

Yes

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

Yes

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* 4. How old are you?

18-30 years old

31-40 years old

41-50 years old

51-60 years old

61-70 years old

71-80 years old

81 or over

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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?

Yes

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

Yes

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

Yes

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

Under 18 years old

18-25 years old

26-30 years old

31-40 years old

41-50 years old

51-60 years old

61-70 years old

71-80 years old

81 or over

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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?

Yes

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

Yes

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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?

Yes

Not applicable as not experiencing symptoms

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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?

Yes

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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)

Not applicable - no support required

Benefits advice

Food shopping or access food deliveries

Collecting medication or prescriptions

Issues with your own health

Issues with the health of the person you care for

Keeping in touch with friends or other carers

Worries about being able to continue to receive services or packages of care

Work (job) related concerns

Carer Breakdown

Family vulnerability

General anxiety over Covid

Home Schooling

Housing issues

Mental Health issues

Hospital/medical appointments

Other - please use this box to tell us about any other support needs or worries that you may have

Wirral Carers Health and Wellbeing Service - Carers online Wellbeing Check.

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

Question Title

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

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

Question Title

* 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.