Young Carers Referral

A young carer is someone aged 5 – 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 Bucks can support you. Please complete the registration form below to register/refer the young carer into Carers Bucks.

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 Bucks 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)

    How did you hear about Carers Bucks? (required)

    YOUNG CARER’S DETAILS

    Name

    Date of birth

    Age

    Gender

    Ethnicity

    School/Educational Institute

    Disability (if any)

    CARING ROLE

    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 Bucks can best support this young carer?

    PRIMARY CONTACT DETAILS

    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 Bucks?

    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 Bucks

    Home address (must include postcode)

    GP Surgery and contact information

    CONSENT

    Carers Bucks 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 Bucks 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 Bucks and I would like to engage with support they offer.

    Signed (Parent/Guardian)

    Date

    Has the parent/guardian’s consent been given but unable to sign the form? (please tick)
    Yes

    If yes, please state reason for this

    PROFESSIONAL’S REFERRAL

    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)