YOUNG CARERSReferral Form About the Young Carer Young Carer Name (required) Date of Birth (required) Address (required) Town/City (required) County Postcode (required) Phone No. (required) Sex (required) MaleFemale BackNext Parent/Guardian of Young Carer Parent/Guardian Name (required) Relationship to Young Carer (required) Mobile No. (required) Landline No. Email (required) Preferred Method of Contact Mobile No.Landline No.Email BackNext General Practitioner of Client Name of GP (required) Practice Name (required) Address (required) Town/City (required) County Postcode (required) Phone No. (required) 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: BackNext 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: BackNext About the Care Recipient Care Recipient Name (required) Relationship to Young Carer (required) Date of Birth (required) Address (required) Town/City (required) County Postcode (required) Phone No. (required) Sex (required) 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: BackNext About the Person Referring Your Name (required) Relationship to Young Carer (required) Address (required) Town/City (required) County Postcode (required) Phone No. (required) Email (required) Has a carers assessment been conducted? YesNo Type of Referral: 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.
