Young Carers Referral

Online form

To refer a Young Carer, you can use the online form below.

Word form

Alternatively, you can download the form in Microsoft Word format.

To submit the Word version, email it to Young.Carers@thecarerscentre.org.

Additional Documents and help

With either form, you’ll also need the Fair Processing Notice PDF. We also have Referral Guidance available.

If you would like to discuss a referral or have any questions about the form, you can call the Young Carers Team Manager on (01273) 746 222 for more information.

The young person

Name of child (required)

Child's Date of Birth (required)

Child's Gender (required)

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:

You must answer the 8 multiple choice questions. The follow-up questions in italics are optional but very helpful if relevant.

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

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?

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?

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?

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).

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?

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?

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?

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

Add another young person

Young person 2