Who is making this referral?*

First name*

Surname*

Date of Birth*

Address line 1*

Address line 2

Town*

Postcode*

Postal district (e.g. who do you pay your Council Tax to?)*

School*

How many hours of care does the young carer provide per week? This might be physically helping with cooking, cleaning or may be providing emotional support.*

How many people does the young carer look after?*

How long has the young carer been caring?*

Does the young carer have any physical or mental health conditions themselves?*

Has the Young Carer been diagnosed with SEND (Special Educational Needs Disability)?*

Does the Young Carer have an EHCP (Educational Health Care Plan)?*

Is there anything else we should know about the young carer e.g. reduced timetable, or any medical conditions we should be aware of etc.

Please let us know about any other agencies / professionals working with the young carer or your family.  Please include previous support, any waiting lists e.g., social care, family solutions, Counselling services, mental health services, groups at school and school nurse.  This helps us to work in conjunction with other agencies and support the the young carer in the best way we can. It also stops us duplicating work that has already been done and means we can contact them if needed for further information

What does the young carer need support with?*

Reason for referral

Who does the young person care for? What specific responsibilities do they have (e.g., shopping, cooking, emotional support)? How does this impact them (e.g., limited social life, mental health challenges, loneliness)? How do you think AfFC can best support them (e.g. attending Young Carer Club, one-to-one support in school)?*

Gender*

Sexual Orientation*

Ethnicity*

Would the carer describe themselves as having a disability?*

Work / education status of carer*

First name*

Surname*

Gender*

Cared-for diagnosis / condition*

The person the young carer look after is your…*

First name*

Surname*

Phone number*

Email*

Would you like to subscribe to our email updates to keep them up to date with our latest news and details of other support available?*