Young Carers Referral Form

Fill in the form to refer a young person who is acting as a carer to Carers Lewisham.

Parent/guardian contact number

Young Carers Name

Young Carers DOB

Young Carers Address

Parent/guardian name

Parent/guardian Email address

Name of cared for

Cared for relationship to Young Carer?
SiblingParentGrandparentOther
Cared for condition (learning difficulty, autistic, physical disability, mental health condition, substance misue)

Referral name

Referral contact details

What support does your young carers provide for the cared for?

What school does your young person attend?

Would you like us to liaise with the school to let them know they are a young carer so they are aware?
NoYes
Anything else we should know at this moment (before contacting family)