Young Carers Referral

Please ensure all sections of this form are completed with as much detail as possible and that the caring role is really focused on. Once a referral is received we will make contact with the family.

    YOUNG CARERS DETAILS

    Name

    Date of birth

    Age

    Gender

    Ethnicity

    School/Educational Institute

    Disability (if any)

    PRIMARY CONTACT DETAILS

    (In addition, if young carer is over 18 and happy to be contacted directly please provide details below)

    Parent/Guardian’s name

    Main phone number

    Email address

    Parent/Guardian’s name

    Main phone number

    Email address

    Details of family members living in family home

    Home address (must include postcode)

    GP Surgery and contact information

    CONSENT

    Young Carers Bucks relies on voluntary participation. We are only able to accept referrals which the family has consented to and are willing to engage with our services. Young Carers Bucks complies with current Data Protection legislation. This form and the information it holds will be transferred to our secure database, along with all records of any work we do with you. I agree for this referral to be made to Young Carers Bucks and I would like to engage with support they offer.

    Signed (Parent/Guardian)

    Date

    Has the parent/guardian’s consent been given but unable to sign the form? (please tick)
    Yes

    Please state reason for this

    CARING ROLE

    Name of person being cared for

    Relationship of young carer

    Date of birth of the person being cared for

    Gender

    Medical condition/disability (Please state clear diagnosis)

    Impact of condition of young person (Please give details of the nature on their caring role, and the impact it has on their everyday life)

    How do you feel Young Carers Bucks can best support this young carer?

    MULTIAGENCY SUPPORT

    What support has your organisation already provided?

    Are any other agencies already involved with this young person?

    If yes, please state below

    What support will you or other agencies continue to offer?

    Is this young person involved in a Child Protection or Child in Need Plan?

    Allocated Social Worker

    RISK ASSESSMENT

    Is there evidence of, or a history of the following risks associated with the young person?

    A risk to themselves
    No riskLowMediumHigh

    A risk to others
    No riskLowMediumHigh

    If a risk to others, please state who

    Additional comments

    Is there evidence of, or a history of, the following risks associated with this household?

    Aggression
    No riskLowMediumHigh

    Domestic abuse
    No riskLowMediumHigh

    Sexual offences
    No riskLowMediumHigh

    Behaviour towards professionals
    No riskLowMediumHigh

    Additional comments

    Are you aware of environmental dangers associated with home visits? (e.g. access to property, animals, conflict with person outside of home)

    Are you aware of any barriers to accessing our services?

    Would your organisation complete a lone working home visit to this family?

    If no, please provide details

    ANY OTHER INFORMATION

    REFERRER DETAILS

    Name

    Date of referral

    Role (if applicable)

    Organisation (if applicable)

    Phone number

    Email address