Name of referrer*

Referrer Organisation / Role

Referrer Contact Number/Email Address*

Date of referral*

Does the Young Person agree to the referral?*

Does the Family agree to the referral?*

First name(s)*

Surname*

Address line 1*

Town*

Postcode*

Parent/Guardian Contact Number*

Email address*

Young Carer's Date of Birth*

Gender

Ethnicity

GP practice

School

School Contact

Does the school know of the caring role?

Parent/Guardian Details*

Is this a Single Parent Family?

Does the young person have siblings in the home?

Please give details of all people living in the household (siblings, parents, grandparents)

Is the child considered to be a child in need?

Is this a current child protection case?

Are there any known safeguarding concerns?

Please give details of any other professionals involved with the family

First name(s)

Surname

Relationship to the young carer

Address line 1

Town

Postcode

Date of Birth

Ethnicity

Nature of illness/disability

Describe the caring role that the young person is undertaking, providing as much detail as possible about the young person’s responsibilities

What is the impact of caring responsibilities on the young person? (isolation/stress/attainment/attendance)

Derbyshire Carers Association is registered with the Information Commissioner's Office and acts in accordance with the General Data Protection Regulations (GDPR, 2018). Under this legislation, personal information will be treated securely, used fairly and lawfully and not kept for longer than is necessary. I understand that information that I share will be stored in accordance with GDPR and a computer record will be created. I have consent of someone with parental responsibility for the child, and of the child where appropriate, whom I am referring. I agree to my details as the referrer (name, organisation, and contact details) will be stored securely by DCA. I am aware I can withdraw this consent at any time. For more information, please visit www.derbyshirecarers.co.uk or call 01773 833833 to request copies of our data retention and sharing policies.*