Referral Form for YC (Professionals)

PRIVACY STATEMENT – PLEASE READ THIS TO THE CARER BEFORE MAKING REFERRAL

Are you happy for the Carers Centre to record your information? This is so that they can offer you support and advice in your caring role. They will not share your information with any other agencies unless they have your permission.
The Young Carer
Carer Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender

FemaleMaleprefer not to answer
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number*
Ethnic Group

WhiteMixed or multiple ethnic groupsAsian, Asian Scottish, Asian BritishAfrican Caribbean or BlackOther Ethnic BackgroundNot Disclosed-Not Known

Living with the Young Carer

School
School Year
Does the Young Carer have any diagnosed illness or disability?
Does the Young Carer have any behavioural or social problems?
Does the family know about this referral?

YesNo
Do you want to speak to a member of staff before we contact the family?

YesNo
Please note: By submitting this form to Dumfries & Galloway Carers Centre you are confirming that you have read the Privacy Statement to the Young Carer & Parent/Guardian.
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Referral Form (Professionals)