St Helens Young Carers Centre

Professional Referral

Professional Referral Of Young Carers

To Download a word version of our referral form click here

If you would like to refer a Young Carer living in St Helens to us please complete the form below. We will acknowledge the referral and may contact you for further details.

Professional Young Carer Referral Form

Referrers Name

Referrers Email

Referrers Contact Telephone Number

Agency/Organisation You Work For

Your Position / Job Title

Full Name Of Young Person

Address of Young Person

I Confirm that this Young Person Lives in a St Helens Postcode

Yes

Date of Birth of Young Person If Known

Age of Young Person

Young Person Own Telephone Number

Young Person Own Email Address

Young Person School/College

Have You Spoken To The YP About This Referral

Parent/Guardian Name

Parent/Guardian Contact Number

Email Address For Parent/Guardian

Opt-In

By ticking, I agree the parent/guardian has given consent for this referral

Who Does the YP Care For and What Are Their Medical Conditions?

Can You Give Details Of Their Caring Role and What Has Resulted To This Referral?

Please specify any significant family and/or safeguarding concerns

Are they currently under Children Social Care

Please Give Details Of Lead Professional

St Helens Young Carers Centre is part of St Helens Carers Centre which is a registered charity in England (No. 1089663)

Registered as a company limited by guarantee in England No. 4203210 Registered Office: 31-35 Baldwin Street, St Helens, WA10 2RS.

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