Carers Emergency Card (CEC) Registration & Care Plan Form
OFFICE USE ONLY
Staff Processing Form:
Emergency Card ID:
Date card issued:
New
Replacement card
If you need assistance to complete this form please contact: 020 8960 3033 Carers Network
Westminster for assistance over the phone or to meet in person.
After completion please return the form using the freepost envelope included.
Carer’s Personal Information:
Mr./Mrs./Miss/Other:
First name:
Surname:
Date of birth:
Gender: Male
Female
Address:
Interpreter Required: Yes
Post code:
No
Religion:
(language):
Relationship to person cared for:
Home Tel:
Receive Carers Allowance: Yes
Work Tel:
Email address:
Carer for an Adult
First name:
Date of birth:
Gender: Male
Young Carer
Surname:
Female
Address:
Has Support Package
Parent Carer
SWIFT ID (OFFICE USE ONLY):
Mr./Mrs./Miss/Other:
Home Tel No:
No
Mobile No:
Details of person cared for:
Interpreter Required: Yes
Ethnicity:
Ethnicity:
Post code:
No
Religion:
(language):
Mobile No:
Work Tel:
Name of Care Agency:
GP Name:
Receive Direct Payments
Tel No:
GP Address:
Have you had a carer’s assessment?
Would you like to have a carer’s assessment if you
Yes No
have not yet had one? Yes
No
Is the person you care for known to Social Services/Mental Health Teams? Yes
No
Care Manager/Social Worker/Care Coordinator/Case Manager’s name:
Contact number:
Team:
Are there any service providers who know the person being cared for? Yes
No
Give details e.g. a care agency, a respite/care/nursing home, a day centre, a personal assistant
paid with direct payments etc who can be contacted to provide care service in an emergency
1
Details for named contact in an emergency: (Up to 3 contacts, if applicable)
First Contact:
Mr./Mrs./Miss/Other:
First name:
Surname:
Address:
Post code:
Relationship to person cared for:
Home Tel:
Interpreter: Yes
Work Tel:
No
(language)
Mobile No:
Second Contact:
Mr./Mrs./Miss/Other:
First name:
Surname:
Address:
Post code:
Relationship to person cared for:
Home Tel:
Interpreter: Yes
Work Tel:
No
(language)
Mobile No:
Third Contact:
Mr./Mrs./Miss/Other:
First name:
Surname:
Address:
Post code:
Relationship to person cared for:
Home Tel:
Interpreter: Yes
Work Tel:
No
(language)
Mobile No:
If no contacts are named/ emergency contacts are not available to provide care, social
services will provide appropriate emergency care which may include providing a paid care
worker.
Note: All emergency calls made will be notified to the relevant Social Services Team
Access to property:
/Equipment in situ where cared for person live
Cared for person able to open door: Yes
No
Has pendant alarm: Yes
Telecare installed: Yes
No
Key safe installed: Yes
Presence of pets: Yes
No
No
No
Type:
Type of Telecare Equipment:
Key holder’s details if different from nominated persons above
Mr./Mrs./Miss/Other:
First name:
Relationship to person cared for:
Home Tel:
Work Tel:
Surname:
Interpreter: Yes
No
(language)
Mobile No:
You need to make sure named contacts have access to property where the cared for person
lives.
Are there any risks that people going to the house should know for their own safety
and the safety of the person cared for? e.g. deliberate self harm, person’s behaviour being a
risk for example verbal/physical aggression, suicide attempts, wandering, risks to others, confusion
etc
Do you have the message in a bottle in the cared for person’s house where you keep
important information? e.g. medication details, daily routines, care plan etc Yes
No
2
Carers Emergency Card Scheme Care Plan
Does the person you care for have (tick all that apply)
Physical disability, sensory impairment and/or illness 
Mental health (not dementia) 
Dementia Substance misuse 
Other (specify):
Learning disability 
Give details of medical condition(s) or illnesses, health problems or disabilities. Up to
date medication details should not be included here but should be stored in the message in a bottle
as this may change from time to time
Details of communication, hearing and sight needs if relevant:
Give details of difficulties with mobility and equipment used if available:
Other useful Information: Religious/Cultural needs and considerations
Does the cared for person have known allergies? Yes
No
. If yes please explain…
Emergency Care Plan
Please use this example to help complete the care plan
Time
Activities or tasks explaining assistance required
0800-0830 daily
0830-0900 daily
1000-1600
Monday&Friday
1200-1300 daily
0700-1800 daily
Assist John with bathing and dressing, I use equipment (bath lift) for bath transfers
Prepare breakfast of John’s choice – this can be cereal, tea/toast, boiled eggs etc
John goes to the day centre as part of therapy, transport is provided. Disruption in
attendance may cause agitation as he is used to routine.
Home meal service brings ready made meals, able to feed independently
Supervise taking medication and eating evening meal. Dosage box kept on top of
fridge and important medication information is in the message in a box in the fridge
District nurse (contact number 0207 150 …) comes to give weekly injection
Mondays 09:00
Notes:
In summary John needs my assistance for an hour twice daily in the mornings and evenings and has
wheels on meals lunch time independently. Twice weekly he goes to the day centre as part of
therapy and this should not be disrupted unless its necessary (include information here if the cared
for person lives in a residential placement and comes home for specified periods of time)
Note: Please include specialist medical needs and equipment being used e.g. colostomy bags, peg
feeding, medication that requires specialist training to administer etc.
3
Emergency 24-hour Care Plan (list only essential activities/services to be provided
Time
in an emergency)
Activities or tasks explaining assistance required
use 24:00 clock or
am/pm to indicate
day or night time
Notes:
Use extra sheet if required
Did you use another sheet? Yes
No
Date completed:
4
Is the cared for person aware of this registration and care plan? Yes
No
Declaration: I have discussed this registration and care plan (care plan is on pages 3 and 4) with the
person I care for and the person I care for has agreed for me to register. We both agree for any
emergency call made to the Carers Emergency Card scheme to be referred to Westminster Social
Care teams for monitoring and for follow up which may be required. I have also discussed
registration and care plan with nominated contacts and they have agreed to provide care on my
behalf in an emergency. All nominated contacts are over 18 years old.
Name of Carer: ____________________________________________________________
Signature of Carer: _______________________________ Date: ___________________
Name of person Cared for: __________________________________________________
Signature of person Cared for: __________________________ Date: ______________
It is important for us to have up to date records to enable us to provide services effectively
for the person being cared for. Please contact us to update these records when there are
changes before annual review date. We will also contact you annually to update our records.
Note: Carers are responsible for the suitability of the named contacts they nominate.
Westminster City Council and NHS Westminster do not take responsibility.
Please return completed forms using freepost envelope provided or to the free post
address: Carers Emergency Card Scheme, Carers Network Westminster, Office 8, Beethoven
Centre, Third Avenue, London W10 4JL
You will be sent your emergency card once you are registered. Copies of the care plan will be
sent with the card along with extra copies for distribution to the cared for and nominated
contact persons and a ResCard discount booklet.
Thank you for completing the Carers Emergency Card Scheme registration and care
plan form.
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