Adult Carers Referral Form

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.

If you have their permission to share.

First name

Surname*

Gender*

Date of Birth

Primary diagnosis / condition*

The person the carer looks after is their...*

Does the carer live with this person?*

Add another Cared-For

The support the carer needs

What do you (the carer) need support with?*

Please tell us about your caring role (e.g., who you look after and the type of care you provide) and the support you are looking for from us to help you in your caring role.*

When is the best day and time for us to give you (the carer) a call?

By submitting this form you are confirming that the carer has given consent for a referral to be made to Action for Family Carers for support. Where the carer is under 18, their parent or guardian has also provided permission.

It has been explained that relevant information may be shared, where necessary and appropriate, to provide support. This may include sharing with:

Essex County Council, the Essex Child & Family Wellbeing Service and others where we are contracted to deliver services.
Organisations we formally partner with to deliver support - including Essex Carers Support.
Other professionals or services, for example, to make referrals to Essex County Council, Adult Social Care, health services, or other charities that can provide support.

All information will be stored securely and handled in accordance with data protection legislation. Please refer to our Privacy Notice for further details.