Register as a Young Caregiver - Caregivers Connected Gateshead

Please complete the form below to register as a young caregiver with us. After completing the form, we may contact you or the young caregiver to confirm the referral.

Young Caregivers Referral Form – Caregivers Connected Gateshead

Referrer Details

Name(Required)

First Name Last Name

Email Address(Required)

Phone Number

Organisation(Required)

Job Role

Please tell us where you heard about our service

Young Caregiver Details

Name(Required)

First Name Last Name

Gender

Preferred pronouns

Is their gender identify the same as their sex registered at birth?

Yes

Prefer not to say

Preferred Name

Address(Required)

Street Address Town/City Post Code

Phone Number(Required)

Alternative Phone Number

Email Address

Date of Birth(Required)

DD slash MM slash YYYY

Ethnicity(Required)

Religion

Do they have any communication needs, including requiring an interpreter?

Parent / Guardian Details #1

Parent / Guardian Name(Required)

Relationship to young carer(Required)

Address(Required)

Telephone

Parent / Guardian Details #2

Parent / Guardian Name

Relationship to young carer

Address

Telephone

School / Employment / Training Details

Is the Young Caregiver in any of the following:

School / College / University

Training

Employment

NEET

School / Employment / Training: Name and Address

School / Employment / Training: Contact Telephone

School / Employment / Training: Named Contact Person

Caregiver's Emergency Contact Details

Name of Emergency Contact(Required)

First Name Last Name

Relationship to young carer(Required)

Emergency Contact Phone Number

Emergency Contact Email Address

Emergency Contact Address

Young Caregiver's GP Surgery(Required)

Young Caregiver's Caring Role

What roles does the Young Caregiver have?

Practical Care

Emotional Care

Personal Care

Physical Care

Other roles

How many hours per week do they spend caring?

How long have they been caring for?

Has the Young Caregiver received a full assessment? (E.g. CYPS, CAHMS, etc.)

Upload assessment document

Max. file size: 512 MB.

What services and support would the young caregiver like to receive from us?(Required)

One-to-One Support

Young Carer Groups

Young Carer Activities

Counselling

Family Activities

School Drop-Ins

Carer Wellbeing Fund