Young Carers Referral

The young person

First name of child (required) Last name of child (required) Child's Date of Birth (required)

Child's Gender (required)
—Please choose an option—Woman (including trans woman)Man (including trans man)Non-binaryPrefer not to sayIn another way

Is their gender identity the same as the gender they were assigned at birth?
YesNoPrefer not to sayUnknown

Child's Ethnicity (required) Name of School/College (required) Child's Disability or Special Educational Needs (if any, please specify) Please ask the young person the following: (Please complete this with the young person, it is important it reflects their experiences.) You must answer the 8 multiple choice questions. The follow-up questions are optional but very helpful if relevant.

1 Do you carry out personal care, manual handling or administer medication?
SelectDAILYOFTENSOMETIMESRARELYNEVER

1b If relevant, please detail which personal care or medication-related tasks you carry out:
2 Do you get worried/angry/stressed as a result of your caring role?
SelectDAILYOFTENSOMETIMESRARELYNEVER

2b Please detail anything in particular that worries you in relation to your caring role:
3 Is your school life impacted by your caring role?
SelectDAILYOFTENSOMETIMESRARELYNEVER

3b Please detail how school life is impacted by caring role e.g. lateness/absence/bullying/feeling isolated:
4 Is your social life impacted by your caring role?
SelectDAILYOFTENSOMETIMESRARELYNEVER

4b Please detail how social life is impacted by caring role e.g. having to come straight home from school:
5 Do you know what to do and who to contact in an emergency? (Answer 1-5, 5 being very confident).
Select5 (Very Confident)4321 (Very Unsure)

5b If relevant, please give an example of an emergency relating to the caring role which you have faced:
6 Do you feel well supported by the professionals in your life?
SelectDAILYOFTENSOMETIMESRARELYNEVER

6b Please list existing support networks you access e.g. school counsellor/youth club:
7 Do you feel able to make independent choices in your life?
SelectDAILYOFTENSOMETIMESRARELYNEVER

7b Please detail things you feel in control of e.g. courses at school, choosing games to play at home:
8 Do you feel appreciated and proud when helping the person you care for?
SelectDAILYOFTENSOMETIMESRARELYNEVER

8b Please detail how your parents/adults show that they are grateful for the support provided:

The professional

First name of professional referring (required) Last name of professional referring (required) Agency Telephone (required) E-Mail (required) Address (required) Who in the family are you working with? (required) How long do you plan to continue working with the family for (required) Family have been shown the Fair Processing Notice (opens in new window) & consent to The Carers’ Centre and Local Authority storing their details? YesNo

The responsible adult

Family address incl. Postcode (required) First name of Adult living with children (required) Last name of Adult living with children (required) Adult's Date of Birth (required)

Adult's Gender (required)
—Please choose an option—Woman (including trans woman)Man (including trans man)Non-binaryPrefer not to sayIn another way

Is their gender identity the same as the gender they were assigned at birth?
YesNoPrefer not to sayUnknown

Adult's Ethnicity (required) Adult's Telephone Number (required) Adult's E-Mail (important – used to send news of upcoming events)

The cared for person

First name of cared-for person (required) Last name of cared-for person (required) Cared-for person's Date of Birth (required)

Cared-for person's Gender (required)
—Please choose an option—Woman (including trans woman)Man (including trans man)Non-binaryPrefer not to sayIn another way

Is their gender identity the same as the gender they were assigned at birth?
YesNoPrefer not to sayUnknown

Lives at family address? YesNo Diagnosed Health Condition(s) Relation to Young Carer (required)

Existing support

Name of Family/Friend/Partner that supports family Lives at family address? YesNo Type of support they give e.g. emotional/childcare/pick up from school etc Relation to Young Carer(s)

About the referral

Reasons for referral (required)

Risk factors

Safe for lone worker to visit home? YesNo
Support Plan? CiNTAFCP