Counselling 4 Carers – Young Carers On-line Form

Please fill in all the fields marked *

Agency Referral Form
Agency details
Agency Name*
Your Name*
Your Role*
Agency Address*
Postcode*
Tel No.*
Mobile No.*
Agency Email*
Enter Email Confirm Email
Young Carers details
Name*
Address*
Postcode*
Tel No.*
Mobile No.*
Email*
Enter Email Confirm Email
Date of Birth*
DD slash MM slash YYYY
How long have they been a young carer?*
Name of person cared for, their age and relationship to carer*
Name of School/Collage attended*
Contact at School and their position*
Supporting Information*
Please tell us how a course of counselling would help the young carer? Are there any safeguarding concerns we should be aware of?
Note
The trustees regret we are unable to reimburse costs already paid or anything that has been booked, contracted for or reserved prior to our agreement to fund/part-fund the cost.
Consent*
I agree to the privacy policy.
I understand that all information supplied on this application form will be kept strictly confidential and will only be used for the purpose of selection and administration. The information I have given in this application is, to the best of my knowledge, true and accurate. I accept that any false or misleading statements may be sufficient cause for rejecting an application. A copy of our Grant Making Policy is available on our website, www.leonardotrust.org or alternatively from our Broadstone office.

Agency Referral Form