Referral Form - Under 18s | Referral Forms

REFERRER DETAILS

Name: *
Email: *
Date of Referral:
Organisation:
Job Title:
Phone no:
Consent gained from the family for this referral & for Carers Plus Yorkshire to contact them direct: *
Is the Young Carer aware of the referral being made: *

YOUNG CARER DETAILS

Name: *
Gender:
Address Line 1: *
Address Line 2:
Town: *
Postcode: *
Date of Birth: *
School:
Ethnic Origin:
School Year:
From a Military Family:

Yes No
GP Surgery:
Any Health Conditions / Behavioural problems: *

CARED FOR DETAILS

Name: *
Date of Birth:
Address:
Relationship to young carer:
Phone No:
GP Surgery:
Health Conditions:

Contact details for parent / guardian of young carer (if different to Cared For)

Name:
Email:
Address:
Relationship to Young Carer:
Phone No: *
Any additional information relevant to us making contact with parent:
What kind of caring input does the young carer provide:
Is there also an adult leading on providing care:

(If so please consider referring them to our Adult Carers Service)
If yes, what is their relationship to the cared for:
Is the young carer and/or family member being supported by any other agencies:

Yes
No
IMPORTANT: Any Safeguarding / risk / other concerns you feel we should be aware of? :

Yes
No
Explain Risks or other concerns:

CONSENTS

IMPORTANT – if only verbal consent has been gained, please make this clear:

IF THIS SECTION IS NOT COMPLETED, WE CANNOT ACCEPT THE REFERRAL
Parental consent:

please confirm consent to this referral has been given & for the data to be shared with both Carers Plus Yorkshire & the service funder NYCC
Signed: *
Date:

Guidelines for Referrers

Definition of a young carer: A young carer is a young person, who helps to look after someone in the family at home because that person is ill, disabled, has poor mental health or is alcohol or drug dependant. Providing care such as emotional, practical or domestic support. The term does not apply to the everyday and occasional help around the home that may often be expected or given by children in families. The key features for us are that the caring responsibilities persist over time and are important in maintaining the health, safety or day to day wellbeing of the person cared for and/or the wider family.

The Aim of The Young Carers Service: is to empower and equip young carers with the skills they need to manage their caring role and other aspects of their lives. We support young carers who are providing a significant caring role and help them reduce the impact of care on their emotional wellbeing.

NB: The service has limited capacity and unfortunately, we are only able to support one young carer per family; this would usually be the child where there is the most impact of care.

What happens after a referral?
We contact the parent/guardian and complete an initial telephone assessment process. We may also contact you, the referrer, to gather more information.

Alternatively

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