Young Carers Referral Form Young Carers Referral Form The information you enter below will be used to begin a referral procedure with the Young Carer's team at Carers Trust Crossroads Sir Gâr. Please answer all the questions as fully as possible in order for us to provide you with the best help. All information submitted here will be treated with confidentiality, and in accordance with GDPR and our Privacy Policy. This section is for the Young Carer's personal information:Young Carer's Name:*Date of birth:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Young Carer's Address:*Phone Number (Parent/Guardian):Phone Number (Young Carer):Email address (Young Carer):GP surgery (Young Carer):Details of any physical disabilities (Young Carer):Details of any mental health issues (Young Carer):Ethnicity:White - Welsh / English / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy or Irish TravellerAny other White backgroundMixed / Multiple ethnic groups - White and Black CaribbeanMixed / Multiple ethnic groups - White and Black AfricanMixed / Multiple ethnic groups - White and AsianAny other Mixed / Multiple ethnic backgroundAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - ChineseAny other Asian backgroundBlack / African / Caribbean / Black British - AfricanBlack / African / Caribbean / Black British - CaribbeanAny other Black / African / Caribbean backgroundOther ethnic group - ArabAny other ethnic groupPrefer not to say Black / African / Caribbean / Black British African Caribbean School/College attended:Name of course tutor/mentor:The section below is for information of the person being cared for:Their name:Their date of birth:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address (if different to yours):Relationship to you:How long have you been their carer:Details of the illness/disability/condition:Their GP Surgery:This section is for information on the care situation:How would you say you are currently coping with your caring role?*Coping wellJust managingReally strugglingAt crisis pointIf applicable, is there any additional information to let us know about?Extra details:Which language do you prefer to communicate in?*EnglishCymraegReferrer's name:* First Last Phone number (Referrer)*Date:* Date Format: DD slash MM slash YYYY Signature* Tick here to confirm your signature electronicallyIf you are completing the referral on behalf of someone else, please confirm the applicable selection below The young carer knows the referral is being made Their parent/guardian knows about the referral Consent* I agree to the referral information above being used for contactI agree to the referral information above being used to begin a Young Carer's referral process, and that any information collected will be used in accordance with GDPR and our Privacy Policy.EmailThis field is for validation purposes and should be left unchanged.
