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Carer Support Referral Form

Are you making this referral on behalf of somebody 

Pease select an option from the list

Is the carer 18 or over? 

Please select an option from the list

Who's Helping Parent Carers and Young Carers?

Family Action, an organisation with a lot of experience will be supporting Parent Carers and Young Carers.

If you'd like to reach out to Family Action to find out more about their service, you can contact their team on 01228 474172 or email [email protected], or [email protected].

Referrer Details

2.1 Referrer contact details

Please select an option from the menu

Please enter a name in the field

Please enter an email address in the field

Please enter a contact number in the field

2.2 What is your relationship to the Carer? 

Please select an option from the list

Please enter an organisation name in the field

Please enter a job title in the field

Please enter how you heard about us in the field

Please enter your expectations in the field

2.5 Are there any risks that may be encountered if a support worker were to visit the carer as a lone worker? 

Please select an option from the list

Please enter further details below

2.6 What support is needed?

Please select an option from the list

Please give further details in the field below if required

Carer Details

3.1 Carer contact details

Please select an option from the menu

Please enter their name in the field

Please enter their email address in the field

Please enter their phone number in the field

Please enter their residential address in the field

Please enter their town/city in the field

Please enter their full post code in the field

Location

Please select an option from the list

Ward - Carlisle West

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Ward - Petteril

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Ward - North Carlisle

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Ward - Fells & Solway

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Ward - Lakes to Sea

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Ward - Workington Together

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Ward - Whitehaven & Coastal

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Ward - South Cumberland

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3.2 Carer Personal Details

Please enter their date of birth in the field

Gender

Please select their gender

Ethnicity 

Please enter their ethnicity in the field

Religion 

Please enter their religion in the field

Disability and/or Special Education Need

Please select an option

Please enter further details in the field

Particular communication needs such as BSL or interpreter

Please select an option

Please enter further details in the field

3.3 What support is needed?

Please select an option from the list

Please give further details in the field below if required

Please enter further details in the field

3.5 Is the carer being supported by other agencies?

Please select an option

Please enter further details in the field

Cared For Details

4.1 Cared For contact details
Cared For Details

Please select an option from the menu

Please enter their name in the field

4.2 Does the person being Cared for live at the same residential address as the Carer that is being referred? 

Please select an option from the list

If no, state their residential address

4.3 Cared For personal details

Please enter the date of birth in the field

Gender

Please select their gender

Please enter further details in the field

4.5 Are they cared for by professionals and/or other carers than the carer(s) that is being referred?

Please select an option

Please enter further details in the field

Consent

Consent 
Consent 

Declaration for Data Protection

Because of the Data Protection Act signature is needed to say that you agree to Cumberland Carers securely holding and sharing (as appropriate) personal information (including the information on this form), on a computer and in a filing system. It is the policy of the Cumberland Carers that all personal data will be held in accordance with the principles and requirements of Data Protection and other relevant legislation, and that procedures will be put in place to ensure the fair processing of data relating to individuals. Cumberland Carers is a confidential service; you can request further information on confidentiality from us at any time.

I agree to that Cumberland Carers can securely hold and store on computer and in a filing system and share (as appropriate), the information on this form.

Agreement