Birmingham Young Carer Professional Referral
Personal Information
Fields marked with a * must be completed
First Name
Last Name
Date of Birth
Please enter date as DD/MM/YYYY
x
Gender
Please select...
Female
Male
Transgender FTM
Transgender MTF
Other
Prefer Not To Say
Ethnicity
Please select...
White: British
White: Irish
White: Traveller of Irish or Gypsy Heritage
White: European
White: Any Other White Background
Mixed / Multiple ethnic group: White and Black African
Mixed / Multiple ethnic group: White and Black Caribbean
Mixed / Multiple ethnic group: White and Asian
Mixed / Multiple ethnic groups: Other Mixed Background
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Bangladeshi
Asian or Asian British: Any other Asian Background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Other ethnic group: Chinese
Other ethnic group: Arab
Any other ethnic group
Prefer not to say
Does the Young Carer have a Disability/ Health Condition?
Please select...
Yes
No
Address
Address
City/Town
County
Post Code
Who else lives in the house with the young carer?
Contacting the Young Carer
Mobile Number
Do we have permission to send texts or messages on Whatsapp?
Yes
E-mail
Do they have regular internet access outside school?
Yes
No
My School or Job
What School or College does the Young Carer go to?
Are they Working or Volunteering?
Yes
No
Is the work or volunteering
Full Time
Part Time
Contact Name and Phone Number at Phone/College/ Work
About Parent/Guardian
Name of Parent/Guardian
What is their relationship to the Young Carer?
Please select...
Mother / Mom
Father / Dad
Guardian
Brother
Sister
Carer
Grandmother
Grandfather
Other Family Member
Aunt
Uncle
Parent/Guardian's Address
Phone Number
E-mail
Does the Parent/Guardian give permission for the carer to receive help from this service?
Yes
No
We will be sharing your assessment with your parent/guardian, is the carer happy to allow us to do this?
Yes
No
Understanding The Caring Role
Who does the Young Carer look after (The Cared For)?
What is the reason for providing care?
Please select...
Long-term illness (like a parent or sibling being sick for a long time)
Physical or learning disability (helping someone who has trouble moving around or learning)
Mental health problems (like a family member feeling very sad, anxious, or stressed)
Issues with drugs or alcohol (caring for someone who struggles with substance use)
Looking after an elderly relative (helping an older family member who can’t do things on their own)
Short-term illness or injury (caring for someone who is temporarily hurt or sick)
Looking after younger siblings (when a parent isn’t able to take care of them)
Household chores and responsibilities (like cooking, cleaning, or shopping for the family)
Please describe the Cared For's condition / diagnosis and how it affects them
Please give example of how the condition impacts the cared for e.g. do they require a wheelchair or bed-bound
x
Cared For's relationship to Young Carer
Please select...
Aunt
Brother
Child
Cousin
Coworker
Daughter
Employee
Employer
Family
Father
Friend
Grandchild
Granddaughter
Grandfather
Grandmother
Grandson
Husband
Mother
Nephew
Niece
Parent
Partner
Sister
Son
Spouse
Uncle
Wife
Cared For
Cared For's Date of Birth
Please enter date as DD/MM/YYYY
x
Caring Activities
How many hours does the Young Carer spend caring a week?
Please select...
0 - 9 Hours
10 - 49 Hours
50+ Hours
How often do they do the following:
1 = Never
2 = Occasionally
3 = A lot of the time
Domestic Tasks (e.g., cleaning, cooking, washing dishes)
Household Management (e.g., shopping, lifting heavy things)
Personal Care (e.g., helping with dressing, washing, mobility)
Emotional Care (e.g., keeping company, providing supervision)
Sibling Care (e.g., looking after siblings)
Financial and Practical Management (e.g., handling bills, interpreting)
Medication (e.g., collecting prescriptions, giving/reminding to take medication)
Impact of Caring
How does caring make the Young Carer feel? (1 = Very negative, 5 = Very positive)
1
2
3
4
5
Does caring affect their schoolwork? ((1 = Not at all, 5 = Very much)
1
2
3
4
5
Have they missed school because of caring?
Yes
No
Have they been late to school because of caring?
Yes
No
Does caring affect their social life? ((1 = Not at all, 5 = Very much
)
1
2
3
4
5
Do they need more time to themselves? (1 = Not at all, 5 = Very much)
1
2
3
4
5
Does caring affect their physical health? (1 = Not at all, 5 = Very much)
1
2
3
4
5
Does caring affect their emotional health? (1 = Not at all, 5 = Very much)
1
2
3
4
5
What is one thing they like about caring?
What is one thing they dislike about caring?
Is there anything about caring that upsets them?
What would make caring easier for them?
My Goals and Support Network
What do they hope to do in the future?
How much does the caring role affect these plans? (1 = Not at all, 5 = Very much)
1
2
3
4
5
Family members, friends, or professionals who help the carer currently
How often does the carer talk to them about your caring role? (1 = Never, 5 = Very often)
1
2
3
4
5
What professionals help with the caring role (e.g., Teacher, social worker)
How helpful is this support? (1 = Not helpful, 5 = Very helpful)
1
2
3
4
5
Do you know of any services that could help but are not currently using?
Completing the Registration
What support from the Young Carer service do you think the carer will benefit from?
I confirm that I have read and agree to the
privacy policy
I understand how the data will be used and that consent can be withdrawn at any time
How did you hear about our service?
Please select...
BCH Event
Birmingham Council
Carers Card
CERS
Childrens' Trust
GP/Health Professional
GP Link worker/Social prescribing
Home Group/Stonham
Leaflets
Mobilise
Other
Partner Event
Recommendation by Friend/Family
Sandwell Crossroads/DISC
Social Media
Spurgeons
Support group
Unknown
Via Hospital
Via Internet
Walsall Council
Carers Event
Via Community
Via School
Via Partner
Via Carers Project
A Birmingham Carers Hub Project
Via National Lottery Project
Forward Carers
Referral Details
Your Name
Your Organisation
Work Number
Your Email
Details of Young Carers GP
Please list any agencies involved with the family
Is this young person subject to the following
Please select...
Child protection plan
Child in Need plan
Early help Plan
Please include copy of most recent assessment / minutes of last meeting.
If Child Protection, please give brief details of category
Name of Lead professional and/or Social Worker
Please ensure carer is under 18 to complete referral. If they are not, please visit https://birminghamcarershub.org.uk to complete a Adult Carer Referral
Contact Information