Full name
Address
Postcode
Date of Birth
Gender MaleFemaleNon-binaryOther (please specify)
Phone Numbers
Ethnicity WhiteMixed or Multiple Ethnic GroupsAsian, Asian Scottish or Asian BritishAfrican, Caribbean or BlackOther Ethnic BackgroundOther (please specify)
GP Surgery
Does the Young Carer have any health issues or additional support needs?
Does the Young Carer have their own Social Worker? If so, who?
Is the Young Carer currently on the Child Protection Register? YesNo
Has a Young Carers Statement been completed? YesNo
School Attended
Guidance/ Pastarol Teacher
Is the School aware that the young person has a caring role? YesNo
Has the Young Carer, together with their Parent/Guardian, given consent to provide their details and refer them to our organisation? YesNo
Relationship to Young Carer
Illness/Disability of cared for
How long have you been providing care? Less than 1 yearBetween 1 and 5 yearsBetween 5 and 10 yearsBetween 10 and 20 yearsOver 20 years
How many hours do you typically care for per week? Up to 4 hours5-19 hours20-34 hours35-49 hoursOver 50 hours
Is the Young Carer the main Carer?
Who else lives at home?
What does the caring role involve?
How does the caring role impact the Young Carer?
Does the Young Carer currently receive any other services from statutory or voluntary organisations? If so please provide information
Does the Young Carer attend any clubs or groups?
Is there any other information or comments that may be relevant?
Referrers Name
Your Address
Your Workplace/Organisation
Your E-Mail
Your Phone Number
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