NCBS Application

Neurological Care Break Scheme Application

The Neurological Care Breaks Scheme allocates funds to family carers who have a significant complex caring role of someone with a neurological condition. It is currently available in East and West Suffolk. We are sorry but Funding is not available in the Waveney area

Please complete all information for both the family carer & the person being cared for, providing as much detail as possible. This will help us understand the caring role and ensure we make an accurate determination of eligibility.

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What is the start of the postcode of the family carer?

Postcode *

Valid Postcode

Is this family carer in receipt of continuing healthcare funding? *

Please let us know if this changes in the future as it may impact eligibility,

Unfortunately this family carer is not currently eligible for NCBS funding. If you require more information please contact us.

To help us keep our funders informed of the demand for this service from people not currently eligible it would be appreciated if you could provide the details of the family carer and press submit below

Are you the family carer making this referral? *

Please provide us with your contact details. We are sorry but we can only accept referrals on behalf of family carers from professionals. If you are not a professional please ask the family carer to complete this form themselves.

Your Name *

Phone *

Do you consent to Suffolk Family Carers holding your details *

I Consent

Organisation *

Email *

Suffolk Family Carers needs your consent to hold your information. This will be stored in accordance with its privacy statement

Family Carer Details

Your Details

Name *

First

Last

Email *

Phone *

Do you receive the direct payment element for Respite from Social Services

Does this family carer receive the direct payment element for Respite from Social Services

Direct payment element *

The award of a grant under the neurological care break scheme may affect future payments received from Social Services for the respite element of the direct payment.

About the Caring Role

How many hours per day do you provide care? (Please Enter in Hours)

How many hours per day is care undertaken by the family carer? (Please Enter in Hours)

Caring Hours *

Please tell us about your caring role?

Please provide as much detail as possible. This should include details of any personal care you undertake, how many days per week you provide, if this includes waking nights, information on whether you help the person being cared for from bed, chair, toilet etc, and any other complex care and support you provide.

Please tell us about the caring role of family carer?

Please provide as much detail as possible. This should include details of any personal care provided, how many days per week care is provide, if this includes waking nights, information on whether the family carer helps the person being cared for from bed, chair, toilet etc, and any other complex care and support provide by the family carer

Caring Role *

What other tasks do you undertake?

Please provide as much detail as possible. This may include items such as supporting with medication management, household tasks, shopping, financial management etc

What other tasks does the family carer undertake?

Please provide as much detail as possible. This may include items such as supporting with medication management, household tasks, shopping, financial management etc

other tasks undertaken *

Please tell us how your caring role impacts your day to day life?

Please provide as much detail as possible. This may include items such as limiting the time you can spend on hobbies and activities, restricting the time you can spend with family and friends, limits on the length of time you can leave the person you care for alone etc

Please tell us how the caring role impacts the day to day life of the family carer

Please provide as much detail as possible. This can include items such as limiting the time that can be spent on hobbies and activities, restricting the time that can be spent with family and friends, restrictions on the length of time the person being cared for can be left alone etc

Impact of caring *

What currently stops you taking a break from your caring role?

What currently stops the family carer taking a break from their caring role?

Stops break *

If your NCBS application is successful how would you use your break?

Please provide as much detail as possible. This may include things such as, trip to visit your family, attending an event etc

If this NCBS application is successful how will the family carer use the break?

Please provide as much detail as possible. This may include things such as, trip to visit family, attending an event etc

How use break *

What would having a funded break mean to you?

What would having a funded break mean to this family carer?

break mean *

About the Person being cared for

What is the primary condition of the person you care for? (This is not an exhaustive list of conditions covered by NCBS. If you cannot see the condition you require please select "Other" and complete the text box)

What is the primary condition of the person being cared for? (This is not an exhaustive list of conditions covered by NCBS. If you cannot see the condition you require please select "Other" and complete the text box)

Condition List

Corticobasal Degeneration
Epilepsy
Huntington’s Disease
Motor Neuron Disease
Multiple Sclerosis
Multiple Systems Atrophy
Muscular Dystrophies
Parkinson’s Disease
Progressive Supranuclear Palsy
Spinal injury
Stroke
Traumatic Brain iIjury
Other

Please tells us the condtion? *

Can the person you care for be left for 3 hours or longer?

Can the family carer leave the person they provide care to for 3 hours or longer?

Be left for 3 hours *

What other support does the person you care for receive in a week?

Please provide as much information as possible. You may wish to include items such as other family support, paid support, social support or residential care.

What other support does the person being cared for receive in a week?

Please provide as much information as possible. This may include items such as other family support, paid support, social support or residential care.

other support *

Is the person you care for happy for alternative support to be provided to give you break?

Is the person being cared for happy for alternative support to be provided to give the family carer a break?

happy *

Consent

Please confirm you have obtained the consent of the family carer to provide the information contained in this NCBS application to Suffolk Family Carers, and for them to store & process it. This includes being contacted by Suffolk Family Carers about this application.

Please confirm you provide consent for Suffolk Family Carers to store and process the information contained in this NCBS application and for them to contact you about the application