Islington Families Self Referral Form

Name of Local Authority:

Name of Programme:

Your Information

First Name

Last Name

Date of birth (in this format - 19/02/1965)

Telephone

Mobile

Email (please leave blank if you do not have this information)

What is your preferred method of contact?

Address Line 1

Postcode

Country

Gender:

Other Gender

Marital Status:

Other marital status

Ethnicity

Other Ethnicity

Age Category:

Sexual Orientation:

Other sexuality

Is the carer caring as part of a couple?

Please add second carer's name

What do you most need support with?

What else might you need support with?

How many kinship children are in your care?

How long has the child or children been in your care (in years)?

Do you have a special guardianship order?

I would like to join the Kinship Carers Community. (If you tick 'yes', you'll receive emails around events, advice, useful organisations and other relevant information about Kinsip Carers.)

This form is being filled out by a Kinship Staff member

Do you have permission to share details of the kinship carer for the Islington Families Programme?

Data protection

Kinship is committed to making only responsible use of your data. The information you share with will only be used to respond to you directly by our experts. We will not share your data with any 3rd parties. For further details you can view our privacy policy at https://www.kinship.org.uk/privacy-policy

Data protection - please tick the box here to confirm you agree with our privacy policy statement

I Agree

Contact Information