Who is making this referral?*

First name*

Surname*

Date of Birth*

Address line 1*

Address line 2

Town*

Postcode*

Postal district (e.g. who do you pay your Council Tax to?)*

Preferred contact phone number (if over 13)

Email (if over 13)

School*

How many hours of care do you (the young carer) provide per week? 
This might be physically helping with cooking, cleaning or looking after siblings or may be providing emotional support.*

How many people do you (the young carer) look after?*

How long have you (the young carer) been caring?*

Any allergies?

Any Dietary requirements?

Do you (the young carer) have any physical or mental health conditions?*

Further details about any medical conditions / medication requirements

Is there anything else we should know e.g. reduced timetable

Please let us know about any other agencies / professionals working with you (the young carer) or your family.  
Please include previous support, any waiting lists e.g., social care, family solutions, Counselling services, mental health services, groups at school and school nurse.  This helps us to work in conjunction with other agencies and support the you (the young carer) in the best way we can. It also stops us duplicating work that has already been done and means we can contact them if needed for further information

Gender*

Sexual Orientation*

Ethnicity*

Would the carer describe themselves as having a disability?*

Work / education status of carer*

First name*

Surname*

Date of Birth

Gender*

Cared-for diagnosis / condition*

The person you (the young carer) look after is your…*

First name*

Surname*

Your phone number*

Your email*

Would you like to subscribe to our email updates to keep them up to date with our latest news and details of other support available?*

I (the young carer) don't have anybody to talk to about my caring responsibilities*

I (the young carer) miss school or fall behind with schoolwork because of my caring responsibilities?*

I (the young carer) struggle with mental health, low mood or anxiety?*

How does the Young Carer help care for someone?*

What do you (the young carer) need support with?*

Please tell us a bit more about the support needed*