Shared Lives Carer Enquiry Form Thank you for expressing an interest in becoming a Shared Lives Carer. Shared Lives Stoke offer long-term or short breaks support for Adults with Learning Disabilities and day support for Adults with Dementia. To support Adults with a Learning Disability, you need to have a spare bedroom in your home. To support Adults with Dementia, you need to be willing to use your home as a base for day support. We welcome your initial enquiry. We appreciate that at this stage, you may not be certain whether Shared Lives is for you or not! Please provide us with some basic information and we will be in touch. Your name Required Preferred contact number Required Email address Required Your address Required Postcode Required Postcode Lookup I may be interested in providing… Required Long-term support (requires a spare bedroom) Short breaks support Day support Where did you hear about Shared Lives Stoke? Required Social media Word of Mouth Existing Shared Lives Carer Existing Shared Live Adult Internet search engine Social worker Employment Advisor Social prescriber Recruitment event Poster or leaflet