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1. Referrer's full name

2. Organisation referrer works for

3. Referrer's contact details

please provide us with a telephone number & email address

4. Name of Young Carer

5. Young Carers date of birth

6. Young Carers address

7. Parent/ guardians name

8. Contact telephone numbers

9. Parent/ guardians email address

10. Young Carers email address

11. Does the Young Carer have a diagnosis of any special or additional needs?

If yes please detail

12. School details

Including; school name, year and any attendance issues.

13. Reason for referral

14. Name of the person who is cared for

15. Date of birth of the person who is cared for

16. Relation of the Young Carer to the person who is cared for

17. Health condition of the person who is cared for

18. Any further information, including any safeguarding information we need to be aware of.

Is there any important information that may be pertinent to the Support Worker when visiting the home assessment, that you are aware of? If necessary please contact the Young Carer Team directly regarding this

19. Is the Young Carer aware of this referral?

Yes

20. Are the parents/ guardians aware of this referral and have given consent for this information to be shared?

Yes

You can contact us on the following phone numbers:

If you look after someone and would like to find out more information about Carers FIRST please contact us at:

Tel: 0300 303 1555

Email: hello@CarersFIRST.org.uk

If you are a professional and would like to refer a carer to Carers FIRST for support please contact us at:

Tel: 0300 303 1555 (option 2)

Email: referral@CarersFIRST.org.uk

Young Carers Project Referral Form

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