Young Carers Registration Form

Please use this form to register a young carer who lives in the Devon County Council area. The person they support maybe ill, frail, disabled, have a mental health issue or substance misuse problem.

If you need this form in another format or support to complete it please contact us via email youngcarers@devoncarers.org.uk or via telephone 03456 434 435

Consent Information

By completing this form, you confirm that you have consent from the person named below or their parent and that they agree to their information being used to register them onto Devon Carers systems for the purpose of supporting them in their caring role. Any fields marked with an asterisk are mandatory. **

I/they care for:*

Referral Information

Registration Date*

Who is Registering the Young Carer?*

Referrer Name*

Referrer Email Address & Contact Number (and if you are a professional please add your organisation)**

Reason for Registration

Briefly summarise the caring situation and if you are a professional, please add parent/carer name, email address and phone number.**

About the person the young carer provides care to

Relationship of cared for person to young carer:*

How many adults do you/does the young carers provide care for?

How many children under 18 do you/does the young carer provide care for?

The conditions listed below are definitions taken from the Office for National Statistics website. Please select the option that most accurately describes the main condition of the person you/the young carer primarily cares for.

Key: MH = Mental HealthDev = Development Neu = NeurologicalPhy = PhysicalSen = Sensory

Main condition of the adult you primarily care for

Main condition of the child you primarily care for

Young carer details and contact information

Title*

Forename(s)*

Prefers to be known as

Surname*

Date of Birth

Either type in the date or use the calendar to select a date.*

Address line 1 (Flat/House Number & Street)*

Address line 2

Address line 3

Address (Village/Town/City)*

Postcode*

Parents Preferred Method of Communication (or if young carer is aged 16-17, their preference)**

Are there any factors that will affect our ability to engage in conversation with the young carer or family? Are there any risks associated with potential home visits? Is any additional support required, i.e. enabler, translator, advocate etc.? Please specify

Is it OK to leave a message on the landline number? (Without consent we are unable to leave messages)

Young Carers Mobile Number if aged 16-17

Is it OK to leave a message on the mobile number?

Yes

No

Young Carers Email Address if aged 16-17

GP Surgery

Please select GP Practice from the list below. If you can’t find the surgery use the ‘GP Surgery – Unknown’ option. If you/the young carer live out of the Devon County Council area and the GP Practice is not on the list, please select ‘GP Surgery – Out of County’

GP Surgery*

Education

Please select school from the list below. If you can’t find the school select ‘School – Unknown’. If you/the young carer’s school is out of the Devon County Council area and the school is not on the list, please select ‘Out of County - School’. If not in education, select NEET.

School/Education*

Other Information

Is there an early help plan in place?

Yes

No

If yes, Right for Children ID

Is there a social worker involved with the young carer?

Yes

No

If yes, please add name & contact details (email, phone number)

Equality and Diversity Monitoring

These questions will help us check that we have reached a representative section of society and help us to identify inequalities. Those who are in the minority groups may experience isolation, ‘invisibility’ and exclusion and this is particularly true of carers. It is therefore important we take notice of their experience and needs.

You do not have to provide this information, or you may choose to provide only some. Any information you do provide will help us to plan services for all carers.

Gender

Ethnicity

Help note: The ethnicities listed below are taken from the Office for National Statistics website. Please select the option that most accurately describes your ethnic group.

Religious Group

Help note: The religions listed below are taken from the Office for National Statistics website. Please select the option that most accurately describes your beliefs.

Sexual Orientation

Help note: The sexual orientation listed below are taken from the Office for National Statistics website. Please select the option that most accurately describes your sexual orientation.

Thank you for referring this young carer to Devon Carers. See https://devoncarers.org.uk/contact/ for more information on how to get in touch should you need to.