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Who is making this referral?*
Young Carer: Main Details
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?*
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
The Support the Young Carer Needs
Please answer all these questions. If you do not provide sufficient information, we may not be able to process your referral.
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)?*
Young 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*
Would the carer describe themselves as having a disability?*
Work / education status of carer*
Cared-for Details: Who does the Young Carer Look After?
If you have their permission to share
Cared-for diagnosis / condition*
The person the young carer look after is your…*
Parent / guardian details
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?*
Your details as the referrer
The organisation you work for*
Your role*
Your phone number*
Your email*
If you are a professional, by submitting this form you are confirming that the parent / guardian of the young 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.