Young Carer Referral

A young carer is someone aged 8 – 16 years old who cares for a family member due to disability, illness, long-term condition, poor mental health and/or addiction.

Are you a parent/guardian of a young carer or working with someone who is? If so, Carers MK can support you. Please complete the registration form below to register/refer the young carer into Carers MK.

If you are a professional completing the form, a copy of your submitted form will be sent to the email address stated in Professional’s email address field.

For information on how Carers MK stores and uses your personal data, please see our Privacy Notice.

    Are you a parent/guardian to a young carer or a professional making a referral? (required)



    Date of birth




    School/Educational Institute

    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?


    Parent/Guardian’s name

    Main phone number

    Email address

    Parent/Guardian’s name

    Main phone number

    Email address

    Details of family members living in family home

    Is there anyone else within the household you would like to refer to Carers MK?

    Person’s name

    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


    Carers MK relies on voluntary participation. We are only able to accept referrals which the family has consented to and are willing to engage with our services. Carers MK complies with current Data Protection legislation. This form and the information it holds will be transferred to our secure database, along with all records of any work we do with you. I agree for this referral to be made to Carers MK and I would like to engage with support they offer.

    Signed (Parent/Guardian)


    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)

    Organisation (required)

    Professional’s phone number (required)

    Professional’s email address (required)

    Date of referral (required)