Crossroads Care NI

YOUNG CARERS

Referral Form





About the Young Carer



MaleFemale

Parent/Guardian of Young Carer



Mobile No.Landline No.Email

General Practitioner of Client


Does the Young Carer suffer from any medical conditions, disabilities or illnesses?

YesNo

 

If yes, please specify:


Is the Young Carer on any medication?

YesNo

 

If yes, please specify:

About the Situation


Type of care provided by the Young Carer: (please tick all that apply)

Primary CarerSecondary CarerDomesticGeneral CareIntimate CareEmotional SupportOther Care


Please give details of Young Carers roles and responsibilities in and around the home:


Any other relevant information: (e.g. attitude of care recipient, effect on life of young carer)


Does the Young Carer receive help, support or activities from any other agency?

YesNo

 

If yes, please specify:

About the Care Recipient



MaleFemale

Please give details of other family members / significant others, especially if under 18:


Please give details of nature of illness / disability of Care Recipient:


Does the Care Recipient receive help, support or activities from any other agency?

YesNo

 

If yes, please specify:

About the Person Referring



YesNo


Health ServicesFamily/RelationSelfSocial ServicesVoluntary SectorEducationOther

Please Note:

Crossroads will assess this referal based on the information submitted on this form.
This will determine the referral’s priority, as we do have a waiting list for our Young Carers Project.