Action for Young Carers Referral Form
Referred by
Office Use Only
Young Carer ID No.
Area
Received Date
Closed Date
Telephone Assessment / Yes No
Tier
Action for Young Carers Referral Form
For Young Carers living in Nottingham City
Please return the completed form to:
Action for Young Carers
Christopher Cargill House
21-23 Pelham Road
Nottingham
NG5 1AP
Tel: 0115 9629351 / 0115 9629352
Fax: 0115 962 9338
E-mail:
Young Carer’s Personal DetailsIf there is more than one young carer in the family please complete this page for each additional young carer.
Name:
Address:
Post Code:
Home Telephone: / YC’s Mobile:
Parent/Guardian Name:
Miss, Ms, Mrs, Mr / Tel No:
Next of Kin (if different from above)
Emergency Contact 1 Name: / Tel No:
Emergency Contact 2 Name: / Tel No:
Wherever possible we will communicate with the YC and parents/guardians by e-mail, please provide details:
Young Carere-mail:
if appropriate to use
Parent/guardian e-mail:
Date of Birth: / Age: / Gender:
Young Carer’s Ethnic Origin (please put a x in the relevant box) / White British / White - Irish
White – Other / Mixed – White & Black Caribbean
Mixed – White & Black African / Mixed – White & Black Asian
Mixed – Other / Asian or Asian British – Indian
Asian/Asian British - Pakistani / Asian/Asian British - Bangladeshi
Asian/ Asian British - Chinese / Asian or Asian British- Other
Black British – Caribbean / Black British – African
Black British – Other / Gypsy, Roma, Traveller
Other Ethnic group – Arab / Other Ethnic group
Not given
Young Carer’s Religion: (please put a x in the relevant box) / Catholic / Christian
Hindu / Islam
Jehovah’s Witness / Sikh
Non religious / Other
Name of family GP Practice:
Please state if Cared for GP is different to Young Carer / GP Name:
GP Practice Address: / Tel:
Medical, Dietary and emotional needs of YC
Medication type and dosage
Language Spoken: / Language Written:
Communication/Additional Needs (please state if a different communication format is required)
Young Carers School Name:
School Address: / School Tel:
School Contact Name:
Young Carer’s Role (please put a x in the relevant box) / Practical Care / Personal Care / Emotional Care / Physical Care
Other combination (please specify):
Please describe the young carer’s role and any particular areas of concern:
Hours of caring if possible?
Has the young carer received a full Carers Assessment? / Yes (if yes please send assessment with referral) / No
What support is required for the young carer? (please put a X in the relevant box) / One-to One support / Young Carer Groups
Young Carer Activities / Family Activities
Counselling
Person Cared For
If there is more than one cared for in the family please complete this page for each additional person.
Name: / Miss, Ms, Mrs, Mr
Date of Birth: / Age:
Gender:
Relationship to Young Carer:
Condition/Circumstance (please use this space to specify the Cared For’s required):
Language Spoken: (please state if interpreters needed ) / Language Written:
Communication Needs
(if any):
Cared For Condition (please put a x in the relevant box) / Physical / Mental Health / Learning Disability
Sensory / Post Operative / Terminal Illness
Palliative Care / Communication
Other, please state:
Cared For’s Ethnic Origin (please put a x in the relevant box) / White British / White - Irish
White – Other / Mixed – White & Black Caribbean
Mixed – White & Black African / Mixed – White & Black Asian
Mixed – Other / Asian or Asian British – Indian
Asian/Asian British - Pakistani / Asian/Asian British - Bangladeshi
Asian/ Asian British - Chinese / Asian or Asian British- Other
Black British – Caribbean / Black British – African
Black British – Other / Gypsy, Roma, Traveller
Other Ethnic group – Arab / Other Ethnic group
Not given
Cared For’s Religion (please put a x in the relevant box): / Catholic / Christian
Hindu / Islam
Jehovah’s witness / Sikh
Non religious / Other
Cared For’s Economic Status (please put a x in the relevant box) / Working full time / Unemployed / Student full-time
Working part-time / Under 18 / Student part-time
Self Employed / Inactive Poor Health / Retired
Other (please specify):
Has the Cared For received any form of assessment? / Yes / No / If yes please give details:
Household Composition– please list all members of the household stating the following: relationship to carer, date of birthand any other carers within the household.
Name: / Relationship to Young Carer: / Date of Birth/Age: / Please tick if also a carer:
Other Agencies – please list all other agencies/workers currently involved with this family.
Name: / Agency/Role: / Contact Details:
Consent – referrals will only be accepted if consent is given by the family.
Has the family ie. parents/carers agreed to this referral? / Yes / No
Is it ok to initially contact the family directly without contacting the referrer first? / Yes / No
Safeguarding
Are the family involved with any safeguarding procedures e.g. CAF, Priority Family, Child In Need Plan or Child Protection Plan? / Yes / No
If yes, please
give details:
Has consideration been given to use of any safeguarding procedures e.g. CAF, Priority Family, Child In Need Plan or Child Protection Plan? / Yes / No
If yes, please
give details:
Lone Working
Are there any risks we need to be aware of when visiting/contacting the family area/household? (please put a X in the relevant box)
- pets
- violence/aggression
- restricted access to property
- parking issues (eg is a parking permit required)
- any other areas of concern
If yes, to any of the above please
give details:
Family History - Please specify any significant family history we need to be aware of when working with this family.
Would the family be happy to receive an assessment by a Support Worker by any of the following:
(Please put a X in the relevant box)
Face to face / Telephone / Skype / What’s app video call
Referrer Details
Date of referral:
Name:
Role
Agency/Team Name & Address:
Tel:
E-mail:
Signature:
Please return the completed form to:
Action for Young Carers
Christopher Cargill House
21-23 Pelham Road
Nottingham
NG5 1AP
Tel: 0115 9629351 / 0115 9629352
Fax: 0115 962 9338
E-mail:
Version 5 Reviewed Date: 02/08/2016 Review Date: 02/08/2018