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To make a referral, please download, complete and return the form below.


  1. To refer a young carer, please complete this form and return it to with REFERRAL as the email subject or post it to Young Carers – Carers Centre, Carers Trust Heart of England, Coventry Central Library, Smithford Way, Coventry, CV1 1FY.

  2. All sections must be filled in*, if you do not have the information please contact parent/carers before making the referral to obtain the details to ensure there is no delay in the registration process. Incomplete forms will be returned to the referrer.

  3. By sending this referral you confirm that both the family and the young carer involved are aware of this referral being made and are happy to be contacted.

  4. Please ensure that the below consent form is given to families to complete when you make the referral.  It is the family’s responsibility to send the consent form back to us to activate the eligibility to access our activities.  Without a consent form, young carers cannot access our activities.

Please ensure that you have read our PRIVACY NOTICE before completing and returning the forms. 


Referral Form 

Consent Form 

Carers Trust Heart of England

6 Queen Victoria Road, 



024 7610 1040

Carers Trust Heart of England is a registered charity number 1057024

Registered as a company limited by guarantee in England and Wales number 3206963