I confirm that I am a Young Adult Carer aged 16–25 and I provide care for a family member or partner with an illness or disability, mental health condition or an addiction.*

I confirm that I have read Centre 33’s data privacy notice regarding data protection and confidentiality, and I agree to share my data with Centre 33.*

Surname*

First Name*

Date of Birth*

First line of address*

Second line of address*

Town*

Postcode*

Contact number*

Email address*

How would you describe your gender?*

What is your ethnicity?*

Anything else you would like to tell us – eg. Do you have a disability? Do you have any mental health conditions? Do you have ADHD?

What GP surgery are you registered with?*

Are you NEET or at risk of NEET? (not in education, employment or training)

If in education, what school / college / university do you attend?

Any other services involved?

Relationship to Young Adult Carer

Main diagnosed condition*

Does the person you care for have any other condition or information you would like to share?

Do you care for anyone else? Please give details

Please tell us about your caring role – think about the practical tasks you may have to carry out and the way your caring role makes you feel.*

Low mood/sadness

Worry / anxiety

Stress

Low confidence / self-esteem

Sleep issues, tiredness

Self-harm

Suicidal thoughts / attempts

Trauma

Isolation / loneliness

Eating issues

Aspirations

Anger

Education

Bullying

Alcohol / substance misuse

Housing / homelessness

Money/benefits

Others - please give details

Please indicate your preferred method of support:*

Today’s date*