This is a reference page so that you can use the website translator to view the referral form questions in the language of your choice. You will need to complete the form on the previous page which should still be open to you in a separate browser tab.
Carers Details
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*
Full name of parent / person with PR*
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
Please select an option
Young carer's school/college*
Please select an option
Young carer’s gender*
Please select an option...
Man (including trans man)
Woman (including trans woman)
Trans
Non Binary
Prefer not to Say
Unsure
Prefer to Self-Describe
Young carer’s preferred pronouns
Please select an option
She/Her
He/Him
They/Them
Prefer to Self-Describe
Young carer’s ethnic group*
Please select an option
Does the young carer you are referring require an interpreter and/ or translated materials?
Please select an option
Interpreter AND Translation Required
Interpreter Required
Translation Required
No
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
Please select an option
Support Someone Who Is Frail/Elderly
Support Someone With An Autistic Spectrum Condition
Support Someone With A Learning Disability
Support Someone With A Substance Misuse Issue
Support Someone With A Mental Health Condition
Support Someone With A Physical Disability
Support Someone With A Physical Illness
Support Someone With A Life Limiting Illness
Support Someone With An End Of Life Condition
Support Someone With Memory/Cognition Problems
Support Someone With A Mild Cognitive Impairment
Support Someone With A Dementia
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 Details
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
Please select an option...
Man (including trans man)
Woman (including trans woman)
Trans
Non Binary
Prefer not to Say
Unsure
Prefer to Self-Describe
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
Please select an option
Acquired Brain Injury
Adhd
Allergy
Amputee
Arthritis
Asthmatic
Autistic Spectrum
Back Problems
Bowel Condition
Cancer
Cerebral Palsy
Challenging Behaviour
Crohn's Disease
Cystic Fybrosis
Dementia
Diabetes
Diet
Digestive Problems
Dyslexic
Dysphasia
Dyspraxia
Eating Disorder
Eczema
Ent Condition
Epilepsy
Fibromyalgia
Hay Fever
Head Injuries
Hearing Impairments
Heart Conditions
High Blood Pressure
Huntingtons Disease
Hypermobility
Learning Difficulties
Lupus
M.e.
Memory/Cognition Problems
Mental Health
Migraines
Mobility Issues
Motor Neurone
Multiple Sclerosis
Muscular Dystrophy
Musculo Skeletal (Msk)
Neurological
Obesity
Organ Failure
Other
Paraplegic
Parkinson's Disease
Polio
Post-COVID Syndrome
Prader-Willi Syndrome
Raynaud's Syndrome
Respiratory Conditions
Speech Impairment
Spina Bifida
Spinal Injury
Stroke And Aphasia
Substance Misuse
Thalidomide
Thyroid
Tourettes Syndrome
Visual Impairments
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?
Please select an option
Yes
No
Do Not Know
If yes, please give brief description of services’ involvement
See below to add details of another person being cared-for
About the caring role
The following section to be completed by or with the young person being referred
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
Please select an option
Never
Rarely
Sometimes
Often
Daily
1b Additional Notes
2a Do you carry out any physical care, such as pushing wheelchairs, helping someone to stand or move?
Please select an option
Never
Rarely
Sometimes
Often
Daily
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
Please select an option
Never
Rarely
Sometimes
Often
Daily
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
Please select an option
Never
Rarely
Sometimes
Often
Daily
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
Please select an option
Never
Rarely
Sometimes
Often
Daily
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?
Please select an option
Never
Rarely
Sometimes
Often
Daily
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
Please select an option
Never
Rarely
Sometimes
Often
Daily
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
Please select an option
Never
Rarely
Sometimes
Often
Daily
8b Additional Notes
9a Does your caring role ever make you feel extremely sad, lonely, anxious or down?
Please select an option
Never
Rarely
Sometimes
Often
Daily
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
Please select an option
Daily
Often
Sometimes
Rarely
Never
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?
Child Protection Plan
Child in Need Plan
Stepped Down From Plans
Name of allocated social worker (if relevant)
Data Protection
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*
Please select an option...
Yes
No
GDPR Preferences
(Choosing block to below options may slow processing of referral)
Telephone
Please select an option
Allow
Block
Please select an option
Allow
Block
Text messages
Please select an option
Allow
Block
Letters / other materials by post
Please select an option
Allow
Block
Where did you hear about us ?
Please select an option
Access Point E-Mail
Access Point Telephone Message
Adult Social Care
Alzheimer's Society
Amaze
Carers Centre Event
Carers Hub Website
Crossroads
Friend/Family
GP
Hospital Poster
Hospital Staff
MAS
Mental Health ProfessionalPoster/Leaflet
QR Code
Other
Preferred contact method*
Please select an option
Telephone
Text Messages
Post
Referrer Details
Referrer’s name*
Referrer’s email address*
Referrer’s phone number*
Referrer’s organisation and team*
Referrer’s sector*
Please select an option
Primary Care
Hospital
Other Health Setting
Social Services
Education
Private Sector
Voluntary Sector
Friend/Family