Are you a parent/guardian to a young carer or a professional making a referral? (required)
YOUNG CARER’S DETAILS
Date of birth
Disability (if any)
Name of the person being cared for
Relationship of young carer
Date of birth of the person being cared for
Gender of the person being cared for
Medical condition/disability of the person being cared for (Please state clear diagnosis)
Impact of condition on the young carer (Please give details of the nature on their caring role and the impact it has on their everyday life)
How do you feel Carers MK can best support this young carer?
PRIMARY CONTACT DETAILS
Main phone number
Details of family members living in family home
Is there anyone else within the household you would like to refer to Carers MK?
Their date of birth
Their phone number (if different to one already provided)
Their relationship to the person being cared for
Please provide information of any more people in the household who you would like to refer to Carers MK
Home address (must include postcode)
GP Surgery and contact information
Has the parent/guardian’s consent been given but unable to sign the form? (please tick)
If yes, please state reason for this
What support has or will your organisation provide? (required)
Are any other agencies already involved with this young person?
If yes, please state below
Is this young person involved in a Child Protection or Child in Need Plan?
Allocated Social Worker
Please provide information about risk associated with the young person, e.g. to themselves or to others?
Please provide information about risk associated with this household, e.g. aggression, domestic abuse, sexual offenses or behaviour towards professionals?
Are you aware of any barriers to accessing our services?
Would your organisation complete a lone working home visit to this family?
If no, please provide details
Professional’s name (required)
Professional’s role (required)
Professional’s phone number (required)
Professional’s email address (required)
Date of referral (required)