Young Carer - New Enquiry

Privacy Notice

Before you proceed, we would like to draw your attention to our Privacy Notice.

Your privacy and data protection are of utmost importance to us, and we want to ensure that you are fully informed about how we collect, use and protect your personal information.Please take a moment to review our privacy notice.Privacy Policy. I understand that this is NOT a full referral into the young carer service. If you are already working with a family and have consent to make a referral into our service you should use the full Young Carer Support Request form instead. That form generates an immediate support request, reducing the waiting time for the young carer. The details provided in this form may be used by the young carer team to contact the family and discuss with them whether they would like to self-refer, so you must ensure the family knows we will be contacting them and that you have their consent to provide us with their contact details.

I confirm that I have consent to provide you with contact details for the family

Yes

I have read and understood that this is not a referral and will take longer than if I complete a support request form.

I agree

Yes

Note – although this is not a referral we still require you to have the young carer’s parent or guardian’s consent to share their details.

Professionals Details

First Name

Last Name

Job Title

Phone Number

Mobile Number

Professionals Organisation

Please search for the professionals organisation in the box below

Organisation Name

Type of Organisation

City

Postcode

Young Carers Details

Young Carers Constituency

Please include the name of the young carer and the name of a parent with an email address and postcode if possible, or another contact method if not.

Please include the name of the cared for if known.

Details of Support Request

Provisional Support Request Reference ID

Please select the young carers local team from the dropdown below

Please provide a brief description of their caring role and what support you think would help.

Best time to phone

Feedback requested for referral

Assign To

Relationship to Professionals Details Start Date

Activity Subject

All Services - Where did you hear about us?

Activity Date

All Services - Service

All Services - Source

Contact Method