Self Referral Guidelines and Referral Form for Young Carers

SELF REFERRAL GUIDELINES AND REFERRAL FORM FOR YOUNG CARERS.

Anyone can refer a young carer to our service for support. If you're a young carer and would like to refer yourself for our services please complete our self-referral form.

What happens next?

Once we receive your referral we will look at the information you have given us and prioritise the need for an assessment. The outcome will be either:

1. Young carer does not meet the criteria for a young carer and no assessment will take place.

2. Young carer is allocated to a member of the young carersteam for ahome visit.

3. Further information is needed from the referrer before processing any further.

AYoung Carer’s Support Officer will make contact with you to arrange a home visit to find more about your caring situation and to let you know what support services is available to you and your family.

If you have any questions throughout the referral or assessment process, please do not hesitate to contact us on 0208 699 8686.

YOUNG CARER DETAILS

Full Name:
Date of Birth: / Age:
Gender: / Ethnicity:
What school/college do you attend? / Do you have a disability or learning difficulty? If yes, which condition(s)? Yes / No
Home Address (including post code): / Home telephone:
Mobile:
Email:
Facebook:
How would you prefer us to contact you?Please circle: via school email telephone

Name of parent / guardian: Telephone / email:

ABOUT THE PERSON(S) WHO ISCARED FOR

Name: / Date of Birth:
Address (if different from above):
What is their main disability/illness:
Physical Disbility ☐ Learning Disability ☐ Substance Misuse ☐ Mental Health ☐
Is this person taking prescribed medication? Yes ☐ No ☐
How does the disability/illness affect them?
Relationship to you:

MAIN TYPE OF CARING ROLE

Personal Care:
(lifting, washing, dressing, assisting with mobility, toileting, administering medication) / ☐

Household Tasks:

(cooking, cleaning, responsible for laundry, shopping) / ☐

Emotional Care:

(listening to, comforting, encouraging or providing company for the cared for person)

/ ☐

Sibling Care:

(supervision of a sibling with care needs, taking them to school, managing behaviour) / ☐

Other:

(collecting benefits, dealing with bills, interpreting or signing for cared for person)

/ ☐
IMPACT OF MY CARING ROLE? PLEASE TICK
Missing or late for school ☐ Self-harming ☐ Misusing drugs/alcohol ☐ Bullied ☐
Socially isolated☐feel stressed/depressed☐
Please add any information here that you feel may be useful for us to know:

Return form to: Lewisham Carers Centre, Waldram Place, SE23 2LB | TEL: 020 8699 8686

FAX: 020 8699 0634 | Email:

MACA-YC18

Below are some jobs that young carers do to help. Think about the help you have provided over the last month. Please read each one and put a tick in the box to show how often you have done each of the job s in the last month. Thank you.

Never / Some of the time / A lot of the time
1 / Clean your own bedroom
2 / Clean other rooms
3 / Wash up dishes or put dishes in a dishwasher
4 / Decorate rooms
5 / Take responsibility for shopping for food
6 / Help with lifting or carrying heavy things
7 / Help with financial matters such as dealing with bills,banking money, collecting benefits
8 / Work part time to bring money in
9 / Interpret, sign or use another communication systemfor the person you care for
10 / Help the person you care for to dress or undress
11 / Help the person you care for to have a wash
12 / Help the person you care for to have a bath or shower
13 / Keep the person you care for company e.g. sitting with them,
reading to them, talking to them
14 / Keep an eye on the person you care for to make sure they are alright
15 / Take the person you care for out e.g. for a walk or to see friends
or relatives
16 / Take brothers or sisters to school
17 / Look after brothers or sisters whilst another adult is near by
18 / Look after brothers or sisters on your own

Developed for The Princess Royal Trust for Carersby Young Carers International Research and Evaluation,

School of Sociology and Social Policy, University of Nottingham, University Park, Nottingham NG7 2RD.

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