Young Carer Referral
In order to avoid delay please complete all sections as fully as possible
Details of the Child or Young Person Who Helps to Care For Someone
Has the parent/guardian agreed to this referral?
Yes
No
Does the child/young personknow about this referral?
Yes
No
Name:
*
First Name
Last Name
Known as:
Gender/Pronoun:
Date of Birth:
*
-
Month
-
Day
Year
Date
Address:
*
Street Address
Street Address Line 2
City
County
Postcode
Phone number:
Mobile:
*
Email (parent/guardian):
*
Email (Young Carer):
example@example.com
School or College:
GP Surgery:
Ethnicity:
Please Select
White – British
White – Eastern European
Other White Background
Asian/Asian British – Indian
Asian/Asian British-Pakistani
Asian/Asian British-Bangledeshi
Black/Black British – Caribbean
Black/Black British – African
Chinese
Mixed – White & Asian
Mixed – White & Black Caribbean
Any other mixed background
Any other ethnic group
Prefer not to say
Details of adult/s with Parental Responsibility residing with the child
Type a question
Rows
First adult
Second adult (if applicable)
Name
Relationship to child/young person
Phone
Email
Information about the person or people who needs care
Name:
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Relationship to Young Carer:
*
Lives with carer?
*
Yes
No
Nature of illness/disability of the cared-for person/s:
*
Please select all that apply:
Physical Disability
Physical Ill Health
Mental Ill Health
Learning Disability
Substance Misuse
Other
How does this affect them day to day and are they receiving treatment?
Additional Information
Who else lives in the household?
Other Household Members (include Parent or Guardian)
Rows
Name
Relationship to Young Carer
Date of birth (if under 18)
Has Caring Responsibilities? Yes/No
1
2
3
4
5
Significant Others (eg absent parent, foster carers, extended family, family friends etc)
Rows
Name
Relationship to Young Carer
Level of Contact
1
2
3
4
5
Does the Young Carer live in a single parent household?
Yes
No
Please tell us about why you are referring the child/young person. What do they do to help with caring?
Rows
Please tell us here
about how the child/young person’s caring role affects their:
Free time and Fun
Physical Health
Emotional Health
Education and Learning
Other Agencies Providing Support for the Child/Young Person and Family
Please ensure that details of current social worker and/or lead professional are included
Type a question
Rows
Name, Role and Agency
Contact Details
Overview of support/services provided
1
2
3
4
Your Details:
Your Name:
First Name
Last Name
Your relationship to the child/young person:
Phone Number:
-
Area Code
Phone Number
Email:
example@example.com
What's the best way to contact you?
Signature
Submit
Should be Empty: