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Who is making this referral?*
Carer: main details
First name*
Surname*
Date of Birth*
Address line 1*
Address line 2
Town*
Postal district (e.g who do you pay your Council Tax to?)*
Postcode*
Preferred contact phone number*
Email
How many hours of care do you (the carer) provide per week?*
How many people do you (the carer) look after?*
How long have you (the carer) been caring?*
Have you (the carer) recently experienced a change in your caring role?*
Would you like to subscribe to our email updates to keep up to date with our latest news and details of other support available?
How did you (the carer) hear about us?
Carer: additional details
We ask the following questions to help make sure that carers from every background feel comfortable to come to us for support and for reporting to our funders.
Gender*
Sexual Orientation*
Ethnicity*
Do you (the carer) describe yourself as having a disability?*
Work / education status of carer*
Cared-for details: Who does the person look after?
We are required to collect these basic details for reporting to our funders:
Primary diagnosis / condition*
The person the carer looks after is their...*
If you have their permission to share (optional)
First name
Date of Birth
Gender
Does the carer live with this person?
The support the carer needs
What do you (the carer) need support with?*
Please tell us a bit more about the support needed*
Your details as the referrer
The organisation you work for*
Your role*
Your phone number*
Your email*
Would you like to subscribe to our email updates to keep up to date with our latest news and details of other support available?*
Family / Friend
Your details as the family / friend / neighbour
By submitting this form you are confirming that the carer has agreed to a referral being made to Action for Carers for support and they give permission for us to share the information with other professionals to help us provide support (For example, to make referrals to Essex County Council, Adult Social Care, health services or other charities). The details provided will be stored in our database in accordance with data protection legislation. These details may be shared with our Local Authority partners where they are the funder of the service and with organisations we are formally partnered with to deliver support. See our Privacy Notice for further information.