Date of birth
Disability (if any)
Primary Contact Details
(In addition, if young carer is over 18 and happy to be contacted directly please provide details below)
Main phone number
Main phone number
Details of family members living in family home
Home address (must include postcode)
GP Surgery and contact information
Young 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.
Young 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 Young Carers MK and I would like to engage with support they offer.
Has the Parent/Guardian’s consent been given but unable to sign the form? (please tick)
Please state reason for this
Name of person being cared for
Relationship of young carer
Date of birth of the person being cared for
Medical condition/disability (Please state clear diagnosis)
Impact of condition of young person (Please give details of the nature on their caring role, and the impact it has on their everyday life)
How do you feel Young Carers MK can best support this young carer?
What support has your organisation already provided?
Are any other agencies already involved with this young person?
If yes, please state below
What support will you or other agencies continue to offer?
Is this young person involved in a Child Protection or Child in Need Plan?
Is there evidence of, or a history of the following risks associated with the young person?
A risk to themselves
A risk to others
If a risk to others, please state who
Is there evidence of, or a history of, the following risks associated with this household?
Behaviour towards professionals
Are you aware of environmental dangers associated with home visits? (e.g. access to property, animals, conflict with person outside of home)
Are you aware of any barriers to accessing our services?
Would your organisation complete a lone working home visit to this family?
Any Other Information
Date of referral
Role (if applicable)
Organisation (if applicable)