MAKE A REFERRAL Please provide us with as much information as possible. If you have any questions please call us on 01609 780872 Name of person making contact *FirstLastOrganisationRoleEmail *Referral or 'One-Off' Enquiry *Select ...ReferralOne Off EnquiryAge Range of Carer *Select ....8 > 1516 > 2526 > 3536+GenderSelect ...MaleFemaleOtherName of Carer *FirstLastDate of BirthAddressPostcodeTelephone NumberMobile NumberRelationship 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 AgreedI confirm that the I / the carer has agreed for Hambleton and Richmondshire Carers Centre to hold and store the information on this form. *IYesNoI confirm that if the carer’s email address has been provided that contact by email can be made. *IYesNoHave you obtained the consent from the Cared For Person (s) for Hambleton and Richmondshire Carers to hold the information contained about them on this referral? (Note that for a child who is the cared-for, consent may be given by the parent/guardian.) *IYesNoMessageSubmit 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.