Young Carer Referral
In order to avoid delay please complete all sections as fully as possible
Has the parent/guardian agreed to this referral?
Yes
No
Has the child/young person agreed to this referral?
Yes
No
Young Carer's Details
Name:
*
First Name
Last Name
Known as:
Gender/Pronoun:
Date of Birth:
*
-
Month
-
Day
Year
Date
Address:
*
Street Address
Street Address Line 2
City
County
Postcode
Phone number:
Mobile:
*
Email (parent/guardian):
*
Email (Young Carer):
example@example.com
School or College:
GP Surgery:
Ethnicity:
Please Select
White – British
White – Eastern European
Other White Background
Asian/Asian British – Indian
Asian/Asian British-Pakistani
Asian/Asian British-Bangledeshi
Black/Black British – Caribbean
Black/Black British – African
Chinese
Mixed – White & Asian
Mixed – White & Black Caribbean
Any other mixed background
Any other ethnic group
Prefer not to say
Information About Person/s Cared For
Name:
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Relationship to Young Carer:
*
Lives with carer?
*
Yes
No
Nature of illness/disability of the cared-for person/s:
*
Please select all that apply:
Physical Disability
Physical Ill Health
Mental Ill Health
Learning Disability
Substance Misuse
Other
How does this affect them day to day and are they receiving treatment?
Additional Information
Other Household Members (include Parent or Guardian)
Rows
Name
Relationship to Young Carer
Date of birth (if under 18)
Has Caring Responsibilities? Yes/No
1
2
3
4
5
Significant Others (eg absent parent, foster carers, extended family, family friends etc)
Rows
Name
Relationship to Young Carer
Level of Contact
1
2
3
4
5
Does the Young Carer live in a single parent household?
Yes
No
Please specify any significant family and/or safeguarding issues:
Please specify details of any disability or behavioural support needs of the Young Carer:
Please outline in detail the reasons for your referral:
What support has already been provided in respect of the needs of the child/young person? eg information, advice and guidance
What strengths and protective factors does the child/young person have? eg do they attend any clubs or extra-curricular activities? Is school attendance good?
Other Agencies Providing Support for the Child/Young Person and Family
Please ensure that details of current social worker and/or lead professional are included
Type a question
Rows
Name, Role and Agency
Contact Details
Overview of support/services provided
1
2
3
4
Consent
Herefordshire Young and Young Adult Carers CIC make determined efforts to contact parents/guardians, however, when unable to make contact progress of the referral can be delayed. Should we be unable to contact the parent/guardian, does the parent/guardian give consent for us to:
Contact the other agencies identified on the referral form before speaking with the parent/guardian?
Yes
No
Visit their child in school before speaking with the parent/guardian?
Yes
No
Referrer's Details:
Name:
First Name
Last Name
Title or Role:
Agency:
Address
Street Address
Street Address Line 2
City
County
Postcode
Phone Number:
-
Area Code
Phone Number
Email:
example@example.com
Whatwill be your ongoing involvement with the family?
Haveyou visited the family at home? If yes, how recently?
Potentialrisk factors on home visit e.g. violence, environment (e.g. high crime area,smokers), aggressive animals etc.
Signature
Submit
Should be Empty: