CSSL Universal Referral Form (draft)

1
Who is completing this form?* This field is required.
I am a professional referring a Carer
I am a Young Carer or a Parent/Guardian self-referring
I am an Adult/Parent Carer self-referring
2
How did you hear about us? * This field is required.e.g., from a friend or from our website
3
Are you referring a Young Carer or an Adult/Parent Carer?* This field is required.
Young Carer
Adult/Parent Carer
4
Your full name* This field is required.
5
Your organisation* This field is required.
6
Your job title * This field is required.
7
Email* This field is required.
example@example.com
8
Contact number* This field is required.
9
Young Carer's full name * This field is required.
10
Young Carer's date of birth * This field is required.
Date
Day
Month
Year
11
Young Carer Gender * This field is required.
12
Young Carer's primary home address* This field is required.
Address
Address Line 2
City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Young Carer's School * This field is required.
14
Parent/Guardian full name* This field is required.
15
Parent Contact Number * This field is required.
16
Parent email address * This field is required.
example@example.com
17
Preferred method of communication * This field is required.e.g., by email
18
Carer's full name * This field is required.
19
Carer's date of birth * This field is required.
Date
Day
Month
Year
20
Carer Gender* This field is required.
21
Carer's primary home address* This field is required.
Address
Address Line 2
City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Carer's contact number * This field is required.
23
Carer's email address* This field is required.
example@example.com
24
Carer's preferred method of communication* This field is required.e.g., by email
25
Carer's employment status* This field is required.
26
Carer's Living Arrangements * This field is required.
Lives with Cared For
Does not live with Care For
27
Does the Carer have any disabilities?* This field is required.If yes, what is the Carer's main disability? If none, write N/A
28
Brief description of caring role* This field is required.e.g., Sarah helps care for her mother who has MS, assisting with medication and personal care on a daily basis...
Huge
Large
Normal
Small
Ok
Ok
29
What would you like to achieve through this support?* This field is required.E.g., to receive respite opportunities, further information and guidance on unpaid caring...
Huge
Large
Normal
Small
Ok
Ok
30
Data Protection Statement * This field is required.How We Use Your Information Carer Support South Lakes (CSSL) will use the information in this form to assess the referral and determine what support we can offer. We aim to make contact within 2–5 working days. Completing this form does not guarantee a service. What we collect: Basic personal details of the Carer (and parent/guardian if the Carer is under 18), the caring situation, and your contact information. Why we process it: We process this data under legitimate interests (Article 6(1)(f), UK GDPR) to deliver our carer support services. Where special category data is involved (e.g. health information), we process it under Article 9(2)(g) for reasons of substantial public interest. Who sees it: Your information is only accessed by CSSL staff involved in your support. We will not share it with third parties without your consent, unless required by law or where there is a safeguarding concern. How long we keep it: Records are retained for two years after your last contact with us, then securely deleted. Your rights: You have the right to access, correct, or request deletion of your data, and to complain to the Information Commissioner's Office (ICO). Contact us at admin@carersupportsouthlakes.org.uk for any data requests. Full privacy policy: https://www.carersupportsouthlakes.org.uk/
31
GDPR Consent * This field is required.Do you consent for your data to be held and processed by Carer Support South Lakes in line with our Data Protection Statement
YESNO
32
Consent Disclaimer

This referral cannot progress without your consent to hold and process your data. If you wish to change your mind, please press "previous" at the bottom of your screen.
33
Are you self-referring yourself as a Parent Carer?* This field is required.A Parent Carer is someone over the age of 18 caring for a child (under 18) under their guardianship
YESNO
34
Are you a parent of a Young Carer, or hold parental responsibility over a Young Carer? * This field is required.
YESNO
35
Do you give consent for CSSL to store and process data about your child?* This field is required.Including data concerning their health condition
YESNO
36
Young Carer Consent disclaimer

Carer Support South Lakes cannot progress this referral without consent to hold and process data within under our Data Protection Statement.
37
Have you notified the Carer/Family of this referral? * This field is required.
YESNO
38
Your Signature* This field is required.Please sign below to confirm the information provided is accurate to the best of your knowledge
Should be Empty: