Southwark Young Carers To refer a young person aged 8-24 to our service please complete this online referral
What is the young carers' First name? *

What is the young carers' family name? *

What Gender is the Young Carer *

Can we have {{answer_15762842}} date of birth

Please enter the Young Carers Home Address

Please give a full postcode

Please tell us about the young carers parent/guardian?

Please ensure they are aware of this referral
What is their full name *

What is the relationship to the young carer ? *

What is their phone number? *

Please include the area code.  Please indicate if this is an evening or day time number and if they are the best person to contact.
Please give names, ages and relationship to young carer of all other members of the household.

What is the main language spoken at home?

What school does the young carer attend?

Who is the child caring for?

What type of conditions does the "cared for" have? *

Does the young carer have any of the following?

If the young carer has a help plan please upload it here

Please tell us why you are making this referral

How would the young carer benefit from our support
Do any of the concerns listed below pertain to the Young Carer

Do any of the concerns listed below pertain to the Person being Cared for?

Are there any support needs for the young carer - ie allergies, health conditions, disabilities etc

Are there any safety issues within the home that we need to be aware of should the staff team be carrying out a home visit

e.g. dangerous dogs, risks for lone workers, remote location etc ?
Does anyone in the home show dangerous behaviour/known to be aggressive or violent?

Please give details

Almost there... please tell us a little bit about you, the person completing this form

Your Name *

Type of Referring Organisation *

Please give your address


Just in case we need to check any details on this form
Has verbal consent been given for this referral

Please ensure you have discussed this referral with the guardian/parent of the young carer. Please be aware that to comply with GDPR (General Data Protection Regulation) a copy of this referral will be shown to the parent/guardian in order to obtain informed consent. If you have any concerns please call the hub on 0300 111 111 0

How did you hear about Southwark Young Carers?

Thank you. Your young carer's referral form has been submitted successfully. One of our support workers will be in touch within 2 working days. Southwark Young Carers hub can be reached on 0300 111 111 0 or by email