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 Carers Referral Form – Caregivers Connected Gateshead

Consent

A referral will only be accepted if consent is given by the family and the person being cared for.

Date caregiver consent given(Required)

Date young carer consent given(Required)

Date cared for consent given(Required)

Lone Working

Are there any risks to our workers that we need to be aware of when visiting or contacting the family / household?(Required)

Please provide details of the risk to our workers.

Safeguarding, Early Help or TAF

Are the family involved with any safeguarding procedures?

E.g. TAF, Priority Family, Child In Need Plan, active Social Worker

If 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.

If yes, please provide details below.

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 Carer Details

Name(Required)

First Name Last Name

Preferred Name

Preferred pronouns

Gender(Required)

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

Yes

Prefer not to say

Date of Birth(Required)

Young Carer's Caring Role

When did the young carer start caring?

Approximate date required

How many hours per week do they spend caring?

What impact does the caring role have on the young carer?(Required)

Young Carer's Contact Details

Address(Required)

Street Address Town/City Post Code

Phone Number(Required)

Alternative Phone Number

Email Address

Emergency Contacts

Please do not include the details of a parent below. The emergency contact listed will be used if we are unable to contact the parents in an emergency situation.

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 Carer's Additional Information

Ethnicity(Required)

Religion

Written Language

Spoken Language

Does the young carer or their parents/guardians have any communication needs, including requiring an interpreter?

Young Caregiver's GP Surgery(Required)

Does the young carer have any health conditions or disabilities?(Required)

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

Upload assessment document

Max. file size: 512 MB.

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

Other Agencies

Please 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.

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

The person they care for

Name(Required)

Title First Name Last Name

Gender

Date of Birth(Required)

Ethnicity

Address(Required)

The person they care for lives at the caregiver's address

Street Address City Post Code

What Health Conditions and Disabilities does the person have?(Required)

GP Surgery(Required)

If the caregiver provides care for anyone else, please enter their details below.