Young carers online referral form About the young carer Young carer name*: Date of birth*: Address*: Town/City*: County: Postcode*: Phone number*: Sex*: MaleFemaleOtherStep 1 of 5NextParent/guardian of young carer Parent/guardian name*: Relationship to young carer*: Mobile number*: Landline number: Email address*: Preferred method of conact: MobileLandlineEmailStep 2 of 5BackNextGeneral practitioner of young carer Name of GP*: Practice name*: Address*: Town/City*: County: Postcode*: Phone number*: 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*: Step 3 of 5BackNextAbout the care recipient Care recipient name*: Relationship to young carer*: Date of birth*: Address*: Town/City*: County: Postcode: Phone number*: Sex*: MaleFemaleOther 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: 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 carer's 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: Step 4 of 5BackNextAbout the person referring Young carer name*: Relationship to young carer*: Address*: Town/City*: County: Postcode*: Phone number*: Email address*: Has a carers assessment been conducted? YesNo Type of referral: Health servicesFamily/relationSelfSocial servicesVoluntary sectorEducationOtherStep 5 of 5 Please note: Crossroads will assess this referral 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. BackSign up for our newsletter for regular updates from us Sign up today I have read and understood the privacy policy and how my data will be handled. I understand I can unsubscribe from the newsletter at any time. Sign up today