Young Carer Referral Form (5-18years)

Welcome to our Young Carer Referral form.

Please complete a SEPARATE referral form for EACH Young Carer you wish to refer. A Young Carer is anyone aged between 5 - 17 who looks after a family member who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid.

We will be asking you for:

• Information about the Young Carer and the Young Carers parent/guardian.

• Information about the people/person being cared for

• Your information as the referrer

Following referral to the Young Carers Service (YCS), an individual assessment will be completed to determine appropriate support. We aim to safely meet the needs of all young people, staff, and the public during our groups and activities.

While we strive to make reasonable adjustments for Young Carers who may struggle with instructions, emotional regulation, or social engagement, there may be cases where group participation isn’t possible. In such instances, we’ll explore alternative support options.

To help us assess how best to support each young person, please include detailed information about their needs in the referral. Feel free to contact the Young Carer team to discuss referrals further.

Consent to store information
Not StartedCompleted
Please click here to read our privacy statement – https://www.northamptonshire-carers.org/privacy-policy
Consent to store Young Carers information
Not StartedCompleted
When you register with us as a Carer, we will store the details that you give us in our Northamptonshire Carers database. We take your data security and privacy very seriously and we are compliant with the Data Protection Act 2018 and The General Data Protection Regulations. You can withdraw your consent at any time by calling or emailing us to let us know. *
Date of consent*
While we are supporting the Young Carer, we may need to share their information with other organisations who may be able to help them. Whenever we do this, we will discuss it with the Young Carer’s parent/guardian first. Does the Young Carer’s parent/guardian consent to us sharing their information with other organisations?*
Have the family given consent to the referral? (yes/no)If no please gain consent before continuing.*
About the Young Carer
Not StartedCompleted
Young Carers first name*
Young Carers Surname*
Young Carers preferred name
How to pronounce their name*
Young Carer date of birth*
Gender*
Ethnic Group*
Address (line1)*
Address (line 2)*
Address (line 3)*
Address (line 4 Town)*
Address (line 5 County)*
Address (Postcode)*
Local Authority the Young Carer lives in.*
Young Carers Parent/guardian Full Name and Title*
Relationship to Young Carer *
The phone number to contact the Parent/Guardian of the Young Carer, including full name.*
An alternative contact number we can use to contact the Parent/Guardian, including full name.*
Parent/Guardian email address*
GP Surgery*
School/College*
Who is the Young Carer caring for? *
Please describe in as much detail as possible the types of caring being provided by the young person i.e. personal care, medication, sibling responsibilities, emotional support and also any impact on the young person.*
Please describe any mental or physical health issues the young person may have.
Safeguarding Concern*
Safeguarding category*
Is there an EHA (Early Help Assessment) in place (Yes/No)*
About the People I care for
Not StartedCompleted
What is the cared for's first name?*
What is their surname?*
What is the cared for's relationship to the Young Carer?*
What is their gender?*
What is their date of birth?*
What is their ethnic group?*
Please state which health conditions they suffer from.*
Duplicator
About the referrer
Not StartedCompleted
Referral Recieved by (category)*
Referrer First name*
Referrer last name*
Referrers Job Title/relationship to Young Carer*
Organisation (if applicable)
Referrer email address*
Referrer Phone number*

Confirmation Email