Young Carer Support Request

1 Start 2 Complete

This form requires full information about the young carer and their family, as well as consent from the parent/guardian. If you are a professional who wants to tell us about a young carer but you only have limited details, please return to the contact us page of our website and use the Provisional Support Request Form

If you have not obtained consent from the parent or guardian of the young carer, please go to our Provisional Young Carer Support Request

Source of request *

If you are a professional seeking support for a young carer, please select 'Professional' If you are the parent or guardian of a young carer, please select 'Self-referral', unless you are making this request on the advice of a professional, in which case please select "Professional' and add that person's details.

Professional Referrer

First Name *

Last Name *

Job Title

Phone Number

Please include the country code

Mobile phone number

Please include the country code and no spaces

Email *

Please provide your work email

Organisation

The name of the organisation you work for

Please check to see if your organisation is already in our database

If your organisation is not on our database, please type the full name here *

How many Young Carers from the same family do you want to tell us about? *

There is space on this form for up to four Young Carers. If there are more, we will take further details from you when we speak to you. Please only give us details about Young Carers within the same family.

Young Carer

First Name

Last Name

Any other preferred name?

Gender

Date of birth

Day

Month

Year

Street Address

Street Address Line 2

City

Postcode

County

Home phone number

Fill in only if consent is given to contact this way

Young Carer's mobile phone number

Fill in only if consent is given to contact this way

Young Carer's email address

Fill in only if consent is given to contact this way

Further Demographics

Age Group

Sexuality

Ethnicity

Other Ethnicity

Religion

Is the gender the young carer identifies as the same as their sex registered at birth?

Other Gender

Does the young carer consider themselves to have a disability?

Details of Disability

Preferred Language

What is the young carer's main language?

Other Language

School

Name of school *

Please put 'Home' if the young carer is home-schooled

Key contact at school

e.g. Head of Year or Form Tutor. An initial appointment with a young carer worker will be arranged and will take place in school

First Name

Last Name

Job Title

Cautions

Category

Is there anything we should be aware of relating to the Young Carer's own needs (allergies, dietary or behavioural issues)? Are there any other issues for us to be aware of?

There is a family member who is not allowed to know that the young carer team is providing support

There is another organisation who is not allowed to know that the young carer team is providing support

Allergies

Food - specific requirements

Young carer - any additional needs or behaviours

Safety issues if visiting family home

Further information

Please provide further information on any of the issues selected above

Young Carer (2)

First Name

Last Name

Any other preferred name?

Gender

Date of birth

Day

Month

Year

Same address as

Young Carer

Street Address

Street Address Line 2

City

Postcode

County

Home phone number

Fill in only if consent is given to contact this way

Young Carer's mobile phone number

Fill in only if consent is given to contact this way

Young Carer's email address

Preferred Language

Further Demographics

Ethnicity

Religion

School

Name of school *

Please put 'Home' if the young carer is home-schooled

Key contact at school (Young Carer 2)

First Name

Last Name

Job Title

Cautions

Category

Is there anything we should be aware of relating to the Young Carer's own needs (allergies, dietary or behavioural issues)? Are there any other issues for us to be aware of?

There is a family member who is not allowed to know that the young carer team is providing support

There is another organisation who is not allowed to know that the young carer team is providing support

Allergies

Food - specific requirements

Young carer - any additional needs or behaviours

Safety issues if visiting family home

Caution Notes

Young Carer (3)

First Name

Last Name

Any other preferred name?

Gender

Date of birth

Day

Month

Year

Same address as

Young Carer

Street Address

Street Address Line 2

City

Postcode

County

Home phone number

Fill in only if consent is given to contact this way

Young Carer's mobile phone number

Fill in only if consent is given to contact this way

Young Carer's email address

Further Demographics

Ethnicity

Religion

School (Young Carer 3)

Name of school *

Please put 'Home' if the young carer is home-schooled

Key contact at school (Young Carer 3)

First Name

Last Name

Job Title

Cautions

Category

Is there anything we should be aware of relating to the Young Carer's own needs (allergies, dietary or behavioural issues)? Are there any other issues for us to be aware of?

There is a family member who is not allowed to know that the young carer team is providing support

There is another organisation who is not allowed to know that the young carer team is providing support

Allergies

Food - specific requirements

Young carer - any additional needs or behaviours

Safety issues if visiting family home

Caution Notes

Young Carer (4)

First Name

Last Name

Any other preferred name?

Gender

Date of birth

Day

Month

Year

Same address as

Young Carer

Street Address

Street Address Line 2

City

Postcode

County

Home phone number

Fill in only if consent is given to contact this way

Young Carer's mobile phone number

Fill in only if consent is given to contact this way

Young Carer's email address

Further Demographics

Ethnicity

Religion

School (Young Carer 4)

Name of school *

Please put 'Home' if the young carer is home-schooled

Key contact at school (Young Carer 4)

First Name

Last Name

Job Title

Cautions

Category

Is there anything we should be aware of relating to the Young Carer's own needs (allergies, dietary or behavioural issues)? Are there any other issues for us to be aware of?

There is a family member who is not allowed to know that the young carer team is providing support

There is another organisation who is not allowed to know that the young carer team is providing support

Allergies

Food - specific requirements

Young carer - any additional needs or behaviours

Safety issues if visiting family home

Caution Notes

Parent/Guardian

First Name

Last Name

Any other preferred name?

Gender

Same address as

Young Carer

Street Address

City

Postcode

County

Mobile number (preferred)

Fill in only if consent is given to contact this way

Landline

Fill in only if consent is given to contact this way

Preferred Language

Is the parent/guardian a carer as well?

Please tick if the parent/guardian is also a carer

Carer

Where did you hear about us? *

If 'other', please specify

How many people do/does the Young Carer/s care for? *

There is space on this form for up to four cared-for people. If there are more, we will take further details from you when we speak to you.

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Young Carer Support Request