Register as a Young Caregiver chat 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 DetailsName(Required) First Name Last Name Email Address(Required) Phone NumberOrganisation(Required) Job Role Please tell us where you heard about our service Young Caregiver DetailsName(Required) First Name Last Name GenderMaleFemaleNon-BinaryPrefer not to sayPreferred pronouns Is their gender identify the same as their sex registered at birth? Yes No Prefer not to say Address(Required) Street Address Town/City Post Code Phone Number(Required)Alternative Phone NumberEmail Address Date of Birth(Required) DD slash MM slash YYYY EthnicityWhite: English, Welsh, Scottish, Northern Irish or BritishAsian, Asian British or Asian WelshBlack, Black British, Black Welsh, Caribbean or AfricanMixed or Multiple ethnic groupsWhite: IrishWhite: Gypsy or Irish Traveller, Roma or Other WhiteOther ethnic groupReligionNo ReligionChristianBuddhistHinduJewishMuslimSikhOther ReligionDo they have any communication needs, including requiring an interpreter? School / Employment / Training DetailsIs the Young Caregiver in any of the following: School / College / University Training Employment NEET School / Employment / Training: Name and AddressSchool / Employment / Training: Contact Telephone School / Employment / Training: Named Contact Person Caregiver's Emergency Contact DetailsName of Emergency Contact First Name Last Name Relationship to caregiverAuntBrotherChild, Non-BinaryDaughterFatherGrandfatherGrandmotherMotherSisterSonStep BrotherStep DaughterStep FatherStep MotherStep SisterUncleOtherEmergency Contact Phone NumberEmergency Contact Email Address Emergency Contact Address Young Caregiver's Caring RoleWhat 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?0 to 1516 to 3637 to 80Over 80Has the Young Caregiver received a full assessment? (E.g. CYPS, CAHMS, etc.)Yes (please send a copy of the assessment with this referral form)NoUpload assessment documentMax. file size: 512 MB.What services and support would the young caregiver like to receive from us?(Required) Register with Caregivers Connected Gateshead One-to-One Support Young Carer Groups Young Carer Activities Counselling Family Activities School Drop-Ins Carer Wellbeing Fund Household CompositionHow many other people are in the household, excluding the young caregiver?123456+Name Relationship to Young Caregiver Date of Birth DD slash MM slash YYYY Are they a caregiver?YesNoName Relationship to Young Caregiver Date of Birth DD slash MM slash YYYY Are they a caregiver?YesNoName Relationship to Young Caregiver Date of Birth DD slash MM slash YYYY Are they a caregiver?YesNoName Relationship to Young Caregiver Date of Birth DD slash MM slash YYYY Are they a caregiver?YesNoName Relationship to Young Caregiver Date of Birth DD slash MM slash YYYY Are they a caregiver?YesNoName Relationship to Young Caregiver Date of Birth DD slash MM slash YYYY Are they a caregiver?YesNoPlease use this space to tell us about any additional household members.Other AgenciesPlease list all other agencies and workers currently involved with the family.Please include the name of the worker, agency and a method of contacting them if possible.SafeguardingAre the family involved with any safeguarding procedures?E.g. CAF, Priority Family, Child In Need Plan, active Social WorkerYesNoIf yes, please provide details below.Has consideration been given to use any safeguarding procedures?E.g. Priority Family, Child In Need Plan or Child Protection Plan.YesNoIf yes, please provide details below.Lone WorkingAre there any risks to our workers that we need to be aware of when visiting or contacting the family / household?PetsYes – there is a riskNo – there is no riskViolence / AggressionYes – there is a riskNo – there is no riskRestricted access to the propertyYes – there is a riskNo – there is no riskParking IssuesE.g. Is a parking permit required?Yes – there is a riskNo – there is no riskAny other areas of concernYes – there is a riskNo – there is no riskMental Health IssuesYes – there is a riskNo – there is no riskSubstance MisuseYes – there is a riskNo – there is no riskThe person they care forName(Required) MissMr.Mrs.Ms.Mx.Prof.Rev.Dr. Title First Name Last Name GenderMaleFemaleNon-BinaryPrefer not to sayAddress(Required) The person they care for lives at the caregiver's address Street Address City Post Code Date of Birth(Required) DD slash MM slash YYYY EthnicityWhite: English, Welsh, Scottish, Northern Irish or BritishAsian, Asian British or Asian WelshBlack, Black British, Black Welsh, Caribbean or AfricanMixed or Multiple ethnic groupsWhite: IrishWhite: Gypsy or Irish Traveller, Roma or Other WhiteOther ethnic groupReligionNo ReligionChristianBuddhistHinduJewishMuslimSikhOther ReligionUnknownWhat Health Conditions and Disabilities does the person have?(Required)GP SurgeryBeacon View Medical CentreBensham Family PracticeBewick Road SurgeryBirtley Medical GroupBlaydon GP Led Health ClinicBridges Medical Practice, Trinity SquareCentral Gateshead Medical Group, The Health CentreChainbridge Medical PracticeCrawcrook Medical CentreCrowhall Medical Group, Felling Health CentreDr M S Hassan & Partners, South RoadFell Cottage SurgeryFell Tower Medical CentreGlenpark Medical CentreGrange Road Medical PracticeHigh Street Medical CentreHollyhurst Medical CentreLongrigg SurgeryMetro Interchange SurgeryMillennium Family PracticeOldwell Medical PartnershipOxford Terrace Medical GroupPelaw Medical CentreRawling Road SurgeryRyton SurgerySecond Street SurgerySt Albans Medical GroupSunniside SurgeryTeams Medical PracticeThe Grove Medical CentreThe Medical Centre, 1 Rawling RoadWhickham Cottage CentreWrekenton Health CentreGP Out of GatesheadUnknownCaregiver Consent(Required) I have gained consent from the caregiver to share their data and make this referral.To comply with GDPR regulations, we require referral partners to confirm that they have obtained verbal consent from any individual whose information is included on this referral form. This consent must cover permission to process and store their information, including any special category data. Additionally, we require confirmation that the individual has verbally consented to being contacted by us.Date caregiver consent given(Required) DD slash MM slash YYYY Cared For Consent(Required) I have gained consent from the cared for person to share their data and make this referral.To comply with GDPR regulations, we require referral partners to confirm that they have obtained verbal consent from any individual whose information is included on this referral form. This consent must cover permission to process and store their information, including any special category data. Additionally, we require confirmation that the individual has verbally consented to being contacted by us.Date cared for consent given(Required) DD slash MM slash YYYY Data Privacy Consent(Required) I agree to the privacy policy.By submitting this form I agree to sharing my information with Carers Federation according to the Carers Federation privacy policy.