Young Carers Form

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?*

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

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

First name*

Surname*

Gender*

Cared-for diagnosis / condition*

The person the young carer look after is your…*

Add Additional Cared-For Person

Parent / guardian details

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?*

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.