Gloucestershire Young Carers Referral Form

Please see our website for further guidance on making a referral.
This form must be submitted and cannot be saved and returned to at a later date. 
In order to avoid delay please complete all sections as fully as possible.

Consent Information

We cannot accept referrals without parental/legal guardian’s consent for young people under 18, or the Young Persons consent if over 18.
By ticking “Yes” you confirm that you have spoken to the parent/legal guardian or young person (if over 18) and obtained their consent to share their personal information and for Gloucestershire Young Carers to hold and manage this information on their systems. 

Important: Absent Parent’s/Guardian’s consent is required if the referral contains their personal information and/or information about a caring role the young person has for them.

Assessors from Gloucestershire Young Carers make determined efforts to contact parents/guardians or the young person (if over 18).
However, when we are unable to make contact, progress of the referral can be delayed.

Should the assessor be unable to make contact does the parent/guardian or young person (if over 18) give consent for Gloucestershire Young Carers to:

Details of Young Person Being Referred

Please tell us more about the young person and their caring role here.

(If possible, please complete this section with the young person)

Please tell us how the caring role affects the different parts of the young person’s life below

Parent/Legal Guardian’s details

We require at least one method of contacting the Parent/Legal Guardian if the young person is under 18 to process this referral.
If you do not have an email or telephone number please state this in the box entering 0000 or

Information about the person/s cared for

Other Household Members

Significant Others

Referrers Details (person completing this form)