Young Carers Referral Form

KINGSTON CARERS' NETWORK

Young Carers' Project Referral Form

Thank you for your interest in the Young Carers' Project. To get the process started please complete this form to tell us about the young person being referred. Once we have received your referral, someone from the Young Carers' Project team will be in touch with the family to provide more information.

Please complete one form for each young carer you wish to refer.

Date Form Completed*

What borough does the young carer live in?*

Service (Please choose Carer Registration)*

What is your relationship to the person you are referring?*

Do you have the consent of the parent/guardian of the young carer you are referring?*

Please obtain consent from the parent or guardian before completing a referral

Sorry, we can only support young carers in the Royal Borough of Kingston who live with the person they are caring for.Please see www.carers.org for your nearest carers centre.

Type of Organisation*

Organisation Name*

Job Title

Name of Referrer (First name and Surname)*

Referrer Email Address*

Referrer Phone Number

Enter phone number without spaces.*

How did you hear about Kingston Carers' Network?*

About the Young Carer:

Title*

First Name*

Surname*

Date of Birth*

House/Flat Name

House number and Street Name*

Town*

Postcode*

Young Carer’s mobile number (if over 12 years old and consent is given)

Enter phone number without spaces.

Young Carer’s email address (if over 12 years old and consent is given)

School*

Does the parent/guardian give consent for YCP staff to contact the young carers’ school regarding this referral?

Yes

Not known

Gender*

Ethnicity*

Detail the care/support the young carer provides and the impact of this on them.*

Does the young carer have any additional needs?*

Yes

Not sure

Please provide full details of the additional support required by the Young Carer and any support the Young Carer currently receives (Please include the name of any organisations or professionals involved in providing support and their contact details)*

Please select all the following that apply

Registered SEND

EHCP in place

EHAT in place

CIN in place

CP plan in place

Receiving pupil premium (free school meals)

A Young Carer needs assessment has been carried out

About the Parent/Guardian (this person will be used as the emergency contact unless you advise KCN otherwise)

Parent/Guardian Title*

First Name*

Surname*

Relationship to the Young Carer*

Main Phone Number (this will also be used as the emergency number)

Enter phone number without spaces.*

Alternative or home phone number

Enter phone number without spaces.

Email Address*

Details about the person being cared for:

The person being cared for is this Young Carer’s …*

First Name*

Surname*

Date of Birth

Cared For Condition Type*

I understand that Kingston Carers' Network will collect and store on its database any information I provide them in order to advise and support the young carer and family with their caring role. I understand that this information will not be shared with any other organisation without my permission. I have read KCN's Privacy Policy and agree to it. More information regarding how Kingston Carers' Network holds and stores personal information can be found on our website at: https://www.kingstoncarers.org.uk/who-we-are/privacy-policy/ or is available in hard copy upon request by contacting us at: admin@kingstoncarers.org.uk or calling 020-303