Make a Referral

Reason

  • Carer
  • Cared for
  • Reason
  • Consent
  • Send

Young Carer

Name

Referrer

Name of referrer

Organisation/Agency/Other

Address (if different from below)

Email

Telephone

Do you have parent’s permission to refer?

Cared for

Cared for name

Cared for address (if different from carer)

Date of Birth

Main disability/illness

Is this person taking prescribed medication?

How does the disability/illness affect them?

Reason

GPDR

We will never share your personal data with any outside agency or company without your permission unless required to do so by law. You are entitled to view your record at any time by giving us 48 hours notice in writing.

Career Consent

I agree that Carers Lewisham’s staff and volunteers can process my personal details to enable appropriate support to be identified for me and the person I care for.

I give my permission for my personal details to be shared with other partners involved in the delivery of the service in accordance with the new General Data Protection Regulation (GDPR)

I understand I can withdraw my consent at any time by contacting info@carerslewisham.org.uk or 020 8699 8686

I confirm that I am happy to be contacted by

Cared for Consent

I agree that Carers Lewisham’s staff and volunteers can process my personal details to enable appropriate support to be identified for me and my carer.

I give my permission for my personal details to be shared with other partners involved in the delivery of the service in accordance with the new General Data Protection Regulation (GDPR)

I understand I can withdraw my consent at any time by contacting info@carerslewisham.org.uk or 020 8699 8686

Where did you hear?

Consent on behalf of cared for

TO THE CARER: Please fill out the below section only if the Cared for Person is: Under 18 and you are the parent, guardian or tutor; lacking in mental capacity and you have legal rights to sign on their behalf

I agree that Carers Lewisham’s staff and volunteers can process the cared for person’s personal details to enable appropriate support to be identified for them and myself.

I give my permission for the cared for person’s personal details to be shared with other partners involved in the delivery of the service in accordance with the new General Data Protection Regulation (GDPR)

I understand I can withdraw the cared for person’s consent at any time by contacting info@carerslewisham.org.uk or 020 8699 8686

Carers Lewisham
Waldram Place
Forest Hill
London
SE23 2LB

Opening Times:
Monday to Friday 9am-5pm

Carers Lewisham is a Carers Trust Network Partner and is accredited by Advice Quality Standard Mark.

We are funded by London Borough of Lewisham, NHS Lewisham (CCG), Children in Need, Donations and Legacies.

Registered Charity No: 1073592
Company Registered in England No: 3681548

All content copyright Carers Lewisham 2018