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Refer To Us

If you are a carer, or know someone who could benefit from our support, you can make a referral here. Just complete the form below and a support worker will contact the carer (or parent/guardian in the case of a young carer) and arrange a suitable time to meet and complete a carers assessment.

 

If you are referring a Young Carer to us please read the Young Carers Referral Guidelines before completing the referral form.

This Referral Form is NOT to be used to report a concern regarding the safety of a child or adult. If you believe a child or adult is in immediate danger call the Police on 999. If you have a serious concern that requires an immediate safeguarding response to protect a child contact the Safeguarding Hub or Out of Hours Emergency Duty Team on 0333 240 1727. If you have a serious concern about the safety of an adult contact Adult Social Care in the relevant district:

The Form is to be used to refer a child, young person, parent or adult that is providing unpaid care to another person. Once a Carer support worker has reviewed the Referral Form we will make contact with the carer or their parent (if they are under 18 year of age) to talk about completing a carer assessment with them so we and/or other professionals can offer them the support they need. The completion of a referral does not guarantee a service.

The completed referral form will be placed on the Carers electronic record as evidence of the referral. The information requested will be used by the Carer organisation, Council and other involved professionals to meet the Local Authority’s statutory duty to provide the person with a carer assessment and appropriate support. The assessment and support will typically include the processing of personal information related to the carer, person receiving care, those with parental responsibility (when the person referred is under 18 years of age), other carers, others living in the home and other involved professionals.

Carer Referral Form

Part 1 - Referrer Consent

We are unable to progress the referral if you are unable to state yes to at least the first 2 questions. Once this consent is received we will be able to progress the referral. 

You can read our Privacy Notice here.

Do you consent to our processing your personal data and the information you provide on this referral form as stated in the Privacy Notice?
Do you have consent from the person being referred (Carer) to make this referral and share their personal information? If the Carer is under the age of 18 have you received this consent from their parent(s) or guardian?
Do you have consent from the person receiving care (Cared For) to make this referral and share their personal information? If the Cared for is under the age of 18 have you received this consent from their parent(s) or guardian?
Part 2 - Referrer Details

Only provide Organisation name and job title if you are an involved professional.

Part 3 - Parental Responsibility

Parent(s) or Legal guardian contact details.

Part 3 must be completed when the person being referred is under 18.

Part 4 - Carer Details

Please do not provide an email address or phone number for a Carer under the age of 18.

Is the Child or Young Person supported as part of a statutory or multi-agency plan?

If one of the above plans is selected provide key professionals contact details:

Part 5a - First Cared For Details

Please do not provide an email address or phone number for someone that is Cared for under the age of 18.

Is the Child or Young Person supported as part of a statutory or multi-agency plan?

If one of the above plans is selected provide key professionals contact details:

Part 5b - Second Cared For Details

Please do not provide an email address or phone number for someone that is Cared for under the age of 18.

Is the Child or Young Person supported as part of a statutory or multi-agency plan?

If one of the above plans is selected provide key professionals contact details:

Thank you for completing this referral form.


Once a Carer Support Worker has reviewed the Referral Form we will make contact with the carer or their parent (if they are under 18 year of age) to talk about completing a carer assessment with them so we and/or other professionals can offer them the support they need. The completion of a referral does not guarantee a service.

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