Self Referral

Self Referral Form

Please fill out the below form with as much information as possible.

We can chat more when we contact you!

Young Persons Full Name:

Young Persons Date of Birth:

Young Persons Address:

Young Persons Email Address (if applicable):

Young Persons Telephone Number (if applicable):

Young Persons School/College:

Do We Have Consent To Contact Their School If Needed?

Are You Filling In This Referral On Behalf Of Someone Else?

Parent/Guardian Name:

Parent/Guardian Telephone Number:

Parent/Guardian email:

Who Does The Young Person Care For And What Are Their Medical Conditions (eg Mum, Sister, Dad etc):

Briefly Describe The Young Person's Caring Role /Why The Cared For Needs Their Support

What Support Would You Like From Us?

How Would You Prefer For Us To Contact You Initially?

Preferred Time Of Contact:

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.