MAKE A REFERRAL Please provide us with as much information as possible. If you have any questions please call us on 01609 780872 Staff NameDateName of person making contact *FirstLastRoleReferral or 'One-Off' Enquiry *ReferralOne OffAge Range of Carer *5 > 1516 > 2526 > 3536+GenderMaleFemaleOtherName of Carer *FirstLastDate of BirthAddressPostcodeTelephone NumberMobile NumberEmailRelationship to 'cared for'Age of 'cared for'If carer is under 18 years of age please take details for person(s) with parental responsibility:IF THIRD PERSON REFERRAL:Carer / person(s) with parental responsibility has given consent for their details to be passed to, and held, by our organisationIF FIRST PERSON REFERRAL / ENQUIRY:The carer has given their permission for us to hold their details electronicallyIf no consent is given then we must explain we cannot provide support without keeping a record of this to protect both partiesWhere did you hear about us?Contact RecordCarer informed of their right to a Carers Assessment?YesNoRecord any outcome aboveActions AgreedAllocationAdult CarerYoung Adult CarerYoung CarerNFACommentSubmit Information Help you find the information you need as a carer and introduce you to the North Yorkshire Carers Forum. Guidance Guide you through the Health and Social Care systems. Find out what benefits may be available for carers and understand your legal rights Respite Meet other carers and take time out for yourself. Develop new skills which will help you feel more in control of your life and future Support We listen to you and provide a confidential and non-judgemental place to talk.