East Sussex Young Carers
To refer a young person aged 5-18
to our service please complete this online referral
ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE GENERAL DATA PROTECTION REGULATIONS (2018)

If you experience technical difficulties completing this form please call the hub on 0300 777 2011
Start
 
Please be aware that to comply with GDPR (General Data Protection Regulation) a copy of this referral will be shown to the parent/guardian in order to obtain informed consent. If you have any concerns please call the hub on 0300 777 2011

 
Has verbal consent been given for this referral *

We are unable to process a referral unless verbal consent to refer has been obtained from the parent or guardian.
     
 
What is the young carers' First name? *

 
What is the young carers' family name? *

 
What Gender is the Young Carer *





 
Can we have {{answer_10875757}} date of birth

 
Please enter the Young Carers Home Address

 
Please give a full postcode

 
Please tell us about the young carers parent/guardian?

Please ensure they are aware of this referral
 
What is their full name *

 
What is the relationship to the young carer ? *


 
What is their phone number? *

Please include the area code.
 
Please give names, dates of birth, and relationship to young carer of all members of the household.

 
What is the main language spoken at home?

 
What school does the young carer attend?

 
Who is the child caring for?


 
Are there any other agencies working with the family *


 
You have indicated there are other agencies working with the family, please give details below

 
What type of conditions does the "cared for" have? *


 
Please tell us more about the cared for's condition?

this will help us to tailor the support we can offer the whole family
 
Does the young carer have any of the following? *


 
If the young carer has a help plan please upload it here

 
Please tell us why you are making this referral

How would the young carer benefit from our support
 
Do any of the concerns listed below pertain to the Young Carer


 
Do any of the concerns listed below pertain to the Person being Cared for?


 
Are there any support needs for the young carer - ie allergies, health conditions, disabilities etc

 
Are there any safety issues within the home that we need to be aware of should the staff team be carrying out a home visit

e.g. dangerous dogs, risks for lone workers, remote location etc ?
 
Does anyone in the home show dangerous behaviour/known to be aggressive or violent?

     
 
Please give details

 
Almost there... please tell us a little bit about you, the person completing this form

 
Your Name *

 
Could we please have your job title?

 
Please can we have the name of your organisation

Please skip if not applicable
 
Type of Referring Organisation *


 
Please give your address

 
Telephone?

Just in case we need to check any details on this form
 
How did you hear about East Sussex Young Carers?

Thank you.
Your young carer's referral form has been submitted successfully.  One of our support workers will be in touch within 2 working days.  A copy of this referral will be emailed to you, (if you provided your email address). Should you experience technical difficulties please contact the Hub.  East Sussex Young Carers hub can be reached on 0300 777 2011 or by email info@eastsussexyoungcarers.org.uk