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Register or Refer

Step 1 of 22 - Start your registration

Use this online form to register yourself, your child or refer someone else to receive support from Carers in Hertfordshire.

If you prefer, you can download a form to register yourself below, or visit our Make a Referral page if you would like to download a form to refer a patient or service user.

Once the registration has been completed, a carer's information pack will be sent, as will future updates about events, and our biannual newsletter Carewaves (carers over 19 only).

Are you looking to register yourself or are you referring someone else?(Required)

I am registering myself

I am referring a patient or service user

I am registering my child as a young carer

I am aged...(Required)

over 18

16 - 18

15 and under

Is your child under 18 years old?(Required)

Yes

As your child is 18 or over, they will need to register themselves using this form.

Do you look after a family member, friend or neighbour?(Required)

They may be ill, disabled, elderly or misuse drugs and/or alcohol. If you used to look after someone and they passed away less than 3 years ago, please also choose 'yes'.

Yes

Do you look after a family member?(Required)

They may be ill, disabled, elderly or misuse drugs and/or alcohol. If you used to look after someone and they passed away less than 3 years ago, please also choose 'yes'.

Yes

Does your child look after a family member?(Required)

They may be ill, disabled, elderly or misuse drugs and/or alcohol. If you used to look after someone and they passed away less than 3 years ago, please also choose 'yes'.

Yes

Do you work, live, or care* in Hertfordshire? Or are you registered with a GP in Hertfordshire?(Required)

* i.e does the person you support live in Hertfordshire?

Yes

Do you live, care or go to school in Hertfordshire? Or is your doctor in Hertfordshire?(Required)

Yes

Does your child live, care or go to school in Hertfordshire? Or are they registered with a GP in Hertfordshire?(Required)

Yes

Sorry, it looks like you are not eligible to register for our support. If this doesn't seem right, please get in touch.

Sorry, it looks like your child is not eligible to register for our support. If this doesn't seem right, please get in touch.

As you are under 16 years old, we will have to contact your parents as part of the registration. Would you like to continue?(Required)

Yes

We're sorry to this is an issue for you. If you think about coming back for help, please don't hesitate to get in touch.

Remember you can always talk to a teacher if you need advice too.

How old is the carer you are referring to Carers in Hertfordshire?(Required)

19 years old and over

16 - 18 years old

Under 16 years old

What kind of organisation do you work for?(Required)

GP surgery

Other healthcare provider (including NHS hospitals)

Any other organisation (e.g local authority, voluntary organisation, pharmacy, care home)

Please ensure that carers are on your carer register.

Have you got a referral form ready to upload or would you rather complete the online form?(Required)

I would like to upload a completed form.

I would like to complete the online form.

Upload the completed referral form.(Required)

Drop files here or

Max. file size: 64 MB.

Please enter your email(Required)

This is in case we have any issues accessing your document.

As the Young Carer is under 16 years old, we will have to contact their parents as part of the referral. Is the Young Carer happy to continue?(Required)

Yes

We cannot accept any referrals made without consent from the parents of the Young Carer. Please try again once you have received consent.

Please confirm that they have given you consent to be referred to Carers in Hertfordshire.(Required)

I confirm that they have given consent

They have not given consent

We cannot accept any referrals made without the Carer's consent. Please try again once you have received consent.

About you, the carer

Title(Required)

Name(Required)

First Last

Date of birth

Day

Month

Year

Address(Required)

Address Line 1 Address Line 2 Town/City County Post Code

Please tell us of any health conditions you have yourself.

Which GP surgery are you registered with?

When did you start caring?

If you are not sure, please give us a rough idea. For example, if you started caring in 2020, you could put 01/01/2020.

Day

Month

Year

Where did you hear about Carers in Hertfordshire?

Your email address

Phone number(Required)

Secondary Phone Number

Additional Information

We ask the following questions to help make sure that carers from every background feel comfortable to come to us for support.

What is your primary language?(Required)

Please specify(Required)

Which ethnicity best describes you?(Required)

Please choose 'Prefer not to say' if you wish.

Please specify(Required)

Religion(Required)

Please choose 'Prefer not to say' if you wish.

Please specify(Required)

Which gender do you identify as?(Required)

Please choose 'Prefer not to say' if you wish.

Is the gender you identify with the same as your sex registered at birth?(Required)

Sexuality(Required)

Please choose 'Prefer not to say' if you wish.

Please self-describe(Required)

Marital status(Required)

Please choose 'Prefer not to say' if you wish.

Employment status(Required)

About the person/people you care for

Please give us their details.(Required)

If you care for more than one person, please use the '+' on the right to add another row.
If someone you cared for passed away less than 3 years ago, please leave a note of when you were bereaved in the 'Their health conditions' column.

Name (Optional)

DOB (Optional)

Their relationship to you (Required)

Their health conditions (Required)

Do you have any specific queries about your caring role that have prompted you to register with us?

Consent

We would like to keep you up to date on our services and free events for carers. Please tell us how you would prefer to be contacted:(Required)

Tick all that apply.

Post

Phone

Text

Withdraw Consent

I understand that I have the right to withdraw consent at any time.

Consent

Click this link view our privacy policy.

I have read and accept the Carers in Hertfordshire Privacy Policy

Who do you look after?(Required)

Tick all that apply.

Mum

Dad

Brother(s)

Sister(s)

Grandparent(s)

Someone else

Please tell us Mum's name.

Mum's date of birth

Day

Month

Year

Please tell us Dad's name.

Dad's date of birth

Day

Month

Year

Please tell us the name(s) of your brother(s).

Your brother's date of birth

Day

Month

Year

If you care for two brothers, please enter the second date of birth here.

Day

Month

Year

Please tell us the name(s) of your sister(s).

Your sister's date of birth

Day

Month

Year

If you care for two sisters, please enter the second date of birth here.

Day

Month

Year

Please tell us the name(s) of your grandparent(s).

Your grandparent's date of birth

Day

Month

Year

If you care for two grandparents, please enter the second date of birth here.

Day

Month

Year

You selected 'Someone else'. Please tell us their name and how you know them.

For example, 'Hannah - cousin'.

Their date of birth

Day

Month

Year

Why do they need your help?(Required)

Is the person you look after disabled, ill or do they misuse drugs or alcohol? Does their condition have a name? If you look after more than one person, please tell us about all of them.

Do you ever want any help?(Required)

A lot of the time

Sometimes

Never

Please tick the boxes for any jobs you do at home to help the person you support.(Required)

Tick all that apply.

Washing up / cleaning / preparing food / loading the washing machine

Going to the shop on your own

Helping someone to communicate – e.g. sign language, reading things out

Helping someone with washing or moving around

Keeping them company

Keeping an eye on younger siblings

I worry about someone...(Required)

all of the time.

some of the time.

none of the time.

About you, the Young Carer

Your name(Required)

First Last

Your date of birth(Required)

Day

Month

Year

Your email address

Your phone number

Your address(Required)

Address Line 1 Address Line 2 Town/City County Post code

Your gender(Required)

You can choose 'Prefer not to say' if you wish.

Please self-describe(Required)

Your ethnicity(Required)

Please choose 'Prefer not to say' if you wish.

Please specify(Required)

Your first language(Required)

Please tell us which language(Required)

Which school do you go to?

School Name Town/City

Your GP surgery

About your parent or guardian

Your parent or guardian's name(Required)

First Last

Your parent or guardian's name

First Last

Their phone number(Required)

Their phone number

Their email address

Their address(Required)

Address Line 1 Address Line 2 Town/City County Post code

Do you consent to Carers in Hertfordshire storing information given on this form regarding your health, any disability and demographic data (e.g. ethnicity, religion, gender)?(Required)

Yes

You acknowledge that all other information supplied on this form will be stored on Carers in Hertfordshire’s secure database and that Carers in Hertfordshire has a duty to share our work with your family with Hertfordshire County Council by recording it on the Council’s EHM system.(Required)

Yes

We will have to contact your parents to get consent to store data on Carers in Hertfordshire's secure database and recording information on Hertfordshire County Council's EHM system. Are you sure you want to continue?(Required)

Yes

You must agree to continue.

About you, the Referrer

Name(Required)

First Last

Email(Required)

Phone

An email will be sent to this address with a confirmation of the referral you have sent to us. Please check you Junk folder if this doesn't come through to you straight away.

Do you work at the Young Carer's school/college?(Required)

Yes

Please tell us where you work and your role there.(Required)

Please tell us the name of the school/college and your role there.(Required)

About the Carer

Title(Required)

Name(Required)

First Last

Date of birth

Day

Month

Year

Address(Required)

Address Line 1 Address Line 2 City/Town County Post Code

Carer's Phone(Required)

Carer's Email

GP Surgery

Please select this option if the carer would like Carers in Hertfordshire to inform their GP of their caring role.

This would enable them to access health checks, flu vaccines and appointments that meet their caring needs.

Inform the carer's GP of their caring role.

Please outline any health conditions the carer has.

Have you already put any support in place for the carer?(Required)

Additional Information about the Carer

If you have this information to hand, it will help us ensure that we can reach carers of all backgrounds. If you do not have this information, please skip to the next section.

Primary language spoken(Required)

Ethnicity(Required)

Please choose 'Prefer not to say' if the carer does not wish to provide this information, or 'No information provided' if you have not been given this information by the carer.

Please describe their ethnicity further.(Required)

Religion(Required)

Please choose 'Prefer not to say' if the carer does not wish to provide this information, or 'No information provided' if you have not been given this information by the carer.

Please describe their religion further.(Required)

Marital Status(Required)

Please choose 'Prefer not to say' if the carer does not wish to provide this information, or 'No information provided' if you have not been given this information by the carer.

Sexuality(Required)

Please choose 'Prefer not to say' if the carer would rather not provide this information.

Please describe their sexuality further.(Required)

Employment status(Required)

Please choose 'Prefer not to say' if the carer does not wish to provide this information, or 'No information provided' if you have not been given this information by the carer.

About the person/people they care for

Please give us their details.(Required)

If the Carer cares for more than one person, please use the '+' on the right to add another row.
If the person they cared for passed away less than 3 years ago, please leave a note of when they were bereaved in the 'Their health conditions' column.

Name (Optional)

DOB (Optional)

Relationship to Carer (Required)

Health conditions (Required)

About the Young Carer

Name(Required)

First Last

Date of birth(Required)

Day

Month

Year

Their GP surgery

Additional Information about the Young Carer

This section helps us ensure that we can reach Young Carers of all backgrounds.

Primary Language(Required)

Gender(Required)

Please choose 'Prefer not to say' if the Young Carer does not wish to give this information.

Please specify their identified gender.(Required)

Ethnicity(Required)

Please choose 'Prefer not to say' if the Young Carer does not wish to provide this information.

Please specify their other ethnicity.(Required)

Religion(Required)

Please choose 'Prefer not to say' if the Young Carer does not wish to provide this information.

Please specify their other religion.(Required)

About you, their parent/guardian

Name(Required)

First Last

Address(Required)

Address Line 1 Address Line 2 City County Post Code

Your Phone(Required)

Your Email

Do you consent to Carers in Hertfordshire securely storing information given on this form regarding health, any disability and demographic data (eg. ethnicity, religion, gender)?(Required)

Yes

You acknowledge that all other information supplied on this form will be stored on Carers in Hertfordshire’s secure database and that Carers in Hertfordshire has a duty to share our work with Hertfordshire County Council by recording it on the Council’s EHM system.(Required)

Yes

You must answer Yes to both of the previous statements to continue with this registration.

About the Young Carer's nominated parent or guardian

This is usually the parent/guardian the Young Carer lives with for the majority of the time, or the person we would be expected to contact first should we need to.

Name(Required)

First Last

Address(Required)

Address Line 1 Address Line 2 City County Post Code

Parent/Guardian's Phone(Required)

Parent/Guardian's Email

Does the parent/guardian consent to Carers in Hertfordshire securely storing information given on this form regarding health, any disability and demographic data (eg. ethnicity, religion, gender)?(Required)

Yes

Please tell us how you obtained this consent.(Required)

The parent/guardian acknowledges that all other information supplied on this form will be stored on Carers in Hertfordshire’s secure database and that Carers in Hertfordshire has a duty to share our work with your family with Hertfordshire County Council by recording it on the Council’s EHM system.(Required)

Yes

The parent/guardian must answer Yes to both of the previous statements to continue with this referral.

About the person/people the Young Carer cares for

Please give us their details.(Required)

If the Young Carer cares for more than one person, please use the '+' on the right to add another row.
If the person they cared for passed away less than 3 years ago, please leave a note of when they were bereaved in the 'Their health conditions' column.

Name (Optional)

DOB (Optional)

Relationship to Young Carer (Required)

Health conditions (Required)

About the caring role

Roughly how long has the Young Carer been caring?(Required)

What tasks do they perform in their caring role?(Required)

Tick all that apply.

Domestic chores

Shopping

Helping to communicate

Personal care

Sibling care

Worrying / Keeping an eye

Please use the space below to explain the caring role of the young person and any other information.(Required)

Please tick any other agencies known to be involved.

Tick all that apply.

0-25 Team

Hertfordshire Adult Care Services

Any Families First team (please specify)

Child in Need Plan

Child Protection Plan

Family Support Worker

CAMHS

Community Mental Health Team

School Nurse

District Nurse

Health Visitor

Any other voluntary organisation (please specify)

Please specify which Families First team is involved.(Required)

Please specify the other voluntary organisation involved.(Required)

(e.g. Hospice, Kids Hub, ADDvance)

What support have these other agencies put in place?(Required)

Is there an open Families First Assessment (also known as EHM)?(Required)

Yes

Unsure

About the person/people your child cares for

Please give us their details.(Required)

Name (Optional)

DOB (Optional)

Relationship to Young Carer (Required)

Health conditions (Required)

About their caring role

Roughly how long has the Young Carer been caring?(Required)

What tasks do they perform in their caring role?(Required)

Tick all that apply.

Domestic chores

Shopping

Helping to communicate

Personal care

Sibling care

Worrying / Keeping an eye

Are any other organisations involved with the caring situation?

Please also describe the support they provide. E.g "Play therapy from school".

Are there any other members of the household not mentioned so far?

Anyone who is not the person/one of the people being cared for, nor the nominated parent/guardian, but they are involved in the caring situation.

Name

DOB

Relationship to Young Carer

About the Young Carer's school or college

School/College Name(Required)

Please also include the town/city where the school is. Alternatively indicate if they are educated at home.

Name of contact at School/College

If known.

Role of contact at School/College

If known.

Phone number for contact at School/College

If known.

Is the school/college aware that the young person is caring?(Required)

Yes

Unsure

Is the school/college aware that your child is a Young Carer?(Required)

Yes

Unsure

Please confirm that you are not a robot.

Download forms to print

Adult Carer Self-Registration Form
Young Carer Self-Registration Form

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