Today's date*

Young carer’s first name*

Young carer’s last name*

Young carer’s date of birth*

Young carer’s address, line 1*

Town

Postcode*

Parent/person with Parental Responsibility's phone number*

Young carer's phone number

Parent/person with Parental Responsibility's email address

Young carer’s email address

Young carer’s GP surgery

Young carer's school/college*

Young carer’s gender*

Young carer’s gender, if they prefer to self-describe

Young carer’s preferred pronouns

Young carer’s ethnic group*

Does the young carer you are referring require an interpreter and/ or translated materials? 

Young carer’s preferred language (if not English)

Does the young carer you are referring have any other communication needs? (No voicemails, large print etc.)

Please select the main reason for which the person they care for needs their support

Does the young carer you are referring have any health conditions or additional needs themselves they would like us to be aware of? 
(Please make sure you have their consent to share any health information)

Cared-for person’s first name*

Cared-for person’s surname*

Cared-for person’s date of birth*

 Cared-for person's postcode

Cared-for person’s gender

Cared-for person’s gender, if they prefer to self-describe

Please state the cared-for’s relationship to the carer *

Please select the main condition for which this person receives support 

Does the cared-for have additional health conditions they’d like us to be aware of?

Is the cared-for person receiving support from any other services?

If yes, please give brief description of services’ involvement

Please briefly describe the caring role and the kind of support the carer feels they may benefit from*

1a Do you carry out any personal care with the person you look after? Such as helping them to get dressed, bathing/washing their hair, helping them get to the toilet or administering medication

1b Additional Notes

2a Do you carry out any physical care, such as pushing wheelchairs, helping someone to stand or move?

2b Additional Notes

3a Do you help the person you look after emotionally? This could be spending time with them, helping them feel less anxious or contacting help if they are having a bad time

3b Additional Notes

4a Do you help the person you look after by doing things around the house or at appointments? This could be cooking, cleaning, food shopping or taking care of your siblings

4b Additional Notes

5a Do you help at home with communication? This may include translating into another language (verbal or written), reading on behalf of someone, or using sign language. It may also mean that you communicate with school or the GP on behalf of your parent

5b Additional Notes

6a Do you get worried, angry, stressed or anxious about your caring role? Do you worry about the person you care for when you are not with them, e.g. when you are at school?

6b Additional Notes

7a Is your social life impacted by your caring role? This might be that you miss doing the same things people your age do because you are needed to help at home, or that you cannot go to or get to clubs and activities

7b Additional Notes

8a Is your school life impacted by your caring role? Lateness due to helping at home, hard to concentrate because you are worrying for the person during school

8b Additional Notes

9a Does your caring role ever make you feel extremely sad, lonely, anxious or down?

9b Additional Notes

10a Do you have people around you that help by supporting or listening to you in relation to your caring role? For example, this could be friends, family, teachers, support workers, social workers

10b Additional Notes

Are you aware of any reason our staff should not conduct a home visit? If yes, please give details*

Are there any other risks or safeguarding issues we should be aware of? If yes, please give details

Is the family the subject of a safeguarding plan?

Name of allocated social worker (if relevant)

Please inform the family that in order to proceed with their referral, their details will be added to our database. The carer and the person they care for can withdraw consent at any time by contacting young.carers@thecarerscentre.org*

Telephone

E-mail

Text messages

Letters / other materials by post

Where did you hear about us ? 

Preferred contact method*

Referrer’s name*

Referrer’s email address*

Referrer’s phone number*

Referrer’s organisation and team*

Referrer’s sector*