This referral form is for Adult (Parent) and Young Carers and should NOT 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 require an immediate safeguarding response to protect a child, contact the Safeguarding Hub or Out of Hours Emergency Team on 0333 240 1727. If you have a serious concern about the safety of an adult, contact Adult Social Care on 0300 303 2704 or Out of Hours Emergency Team on 01228 526690.

This form is used to refer All Age Carers that are providing unpaid care to another person. Once a Carer Support Services Adviser/Carers Health Co-ordination Worker/Young Carers Worker has reviewed the Referral Form we aim to make contact with the Unpaid Carer or their parent (if they are under 18 year of age) within one week 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 Carer Support Furness, Westmorland and Furness 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 Carer Assessment and support will typically include the processing of personal information related to the Unpaid Carer, the person receiving care, those with parental responsibility (when the person referred is under 18 years of age), other Unpaid Carers, others living in the home and other involved professionals.

All Age Carer Referral Form

* Denotes a required field

PART 1 – Referrer Details and Consent for Referral

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

Do you the referrer 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 Carer being referred 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? *

Referrer Details

Address

What is your relationship to the Carer? *
Would you like feedback? *

PART 2 – Adult or Young Carer Details

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

Address

Carer personal details

Disability and/or Special Education Need *
Communication needs such as large print, BSL or interpreter *
Is the Carer under the age of 18? *
Is the child or young person registered to attend formal education (school or college)? *
Is the Child or Young Person supported as part of a statutory or multi-agency plan? *

PART 3 - Parental Responsibility Details for a Young Carer (under 18)

Parent(s) or Legal guardian contact details.

Does the person with parental responsibility live at the same residential address as the child or young person being referred?

Parent(s) or Legal guardian personal details

Communication needs such as large print, BSL or interpreter

PART 4 – Cared for Details

Cared For contact details.

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

Does the person being Cared for live at the same residential address as the Carer that is being referred?

Cared For personal details

Are they cared for by professionals and/or other carers than the Carer(s) that is being referred?
Is the person Cared For under the age of 18?
Is the child or young person registered to attend formal education (school or college)?
Is the Child or Young Person supported as part of a statutory or multi-agency plan?
Select type

I agree to the privacy policy. *