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.

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