I confirm that the young person I am referring provides care for a family member with an illness or disability, mental health condition or an addiction.*

I confirm the young person understands that they are a young carer and consents to this referral being made.*

I confirm that I have shared Centre 33’s data privacy notice regarding data protection and confidentiality with the young person and the young person agrees to share their data with Centre 33.*

Parental permission has been gained to make this referral if the young person is aged under 13*

Consent given to share another person's data?*

Young carers surname*

Young carers first name(s)*

Young carers date of birth*

Young carers first line of address*

Young carers second line of address

Young carers town*

Young carers postcode*

Young carer's contact number*

Young carer's email address*

How does the young carer describe their gender?*

What is the young carers ethnicity?*

Does the young carer / family have any communication needs eg. interpreter required?

Are there any known hazards at the young carers home address that we would need to be aware of if doing a home visit?*

Parent / guardian name

Parent / guardian email address

Parent / guardian contact number

What GP surgery is the young carer registered with?*

What school does the young carer currently attend?*

If known, what is the young carers school attendance?

Does the young carer themselves have any additional needs, difficulties or disabilities?*

Details of any additional needs, difficulties or disabilities

Does the young carer have an EHCP?*

Is the young carer named on an EHA?*

Does the young carer have a CIN plan?*

Is the young carer open to social care under child protection?*

Has the young carer ever been in care?*

Score

Level of care provided

Relationship to the young carer*

Main diagnosed condition (if appropriate)*

Disability / Illness type (if appropriate)*

Other conditions or information about this person

Relationship to the young carer

Main diagnosed condition (if appropriate)

Disability / Illness type (if appropriate)

Other conditions or information about this person

Does the Young Carer care for anyone else?  Please give details

Who lives with the Young Carer?

Who doesn’t live with the Young Carer but means a lot/helps them?

Is this a military family?

Please give details of the care being provided and the impact this is having on the young person.  Please ensure you are capturing the young person’s voice and give as much detail as possible.

Low mood / sadness

Worry / anxiety

Stress

Low confidence / self-Stressesteem

Sleep issues, tiredness

Self-harm

Suicidal thoughts / attempts

Trauma

Isolation / loneliness

Eating issues

Aspirations

Education

Anger

Bullying

Other – please give details

Your name*

What is your relationship to the young person being referred?*

If you are a professional, what is your job title?*

Your email address*

Your contact number*

Please can you tell us how you heard about Centre 33’s Young Carers Service?

Today’s date*