Renfrewshire Carers Centre,

Unit 55 Embroidery Mill,

Abbey Mill Business Centre,

Paisley, PA1 1TJ

Telephone: 0141 887 3643

Email:

Young Carers Project

Referral Form for Professionals

  1. DETAILS OF YOUNG CARER
Please complete a separate form for each person you are referring to us. We are unable to process your referral until this form has been returned.
Name / Ethnic Origin
Gender / Health Issues & Additional Support Needs
Date of Birth
Address (including postcode) / School/College Attended
Guidance Teacher
Is School aware that the person is a Young Carer?
Yes [ ] No [ ]
Is an Additional Support For Learning Plan in place? Yes [ ] No [ ]
Home Phone Number
Mobile Phone Number
Name of Parent/Guardian
Date of Birth
Has the Young Carer, together with his/her parent/guardian, given their consent for you to provide their details and refer them to our organisation for possible service input? Yes [ ] No [ ]
Does the Young Carer have their own Social Worker? If so, who?
Is the Young Carer currently on the Child Protection Register? Yes [ ] No [ ]
  1. DETAILS OF WHO IS BEING CARED FOR

Main person being cared for: / Additional person(s) being cared for:
Name / Name
Relationship to Young Carer / Relationship to Young Carer
Date of Birth / Date of Birth
Address(if different from above) / Address (if different to above)
Telephone number / Telephone Number
Ethnic Origin / Ethnic Origin
Nature of Illness/Disability / Nature of Illness/Disability
  1. INFORMATION ABOUT THE YOUNG PERSON’S CARING ROLE

Dynamics Of Family Household (who lives at home etc)
Please state any risks/safety issues we should be aware of when visiting the family at home
Is the Young Carer the main carer for the person(s) detailed in Section 2 above? Yes [ ] No [ ]
If ‘No’, who else at home is also a Carer?
Name(s)
Relationship(s) to Young Carer
Does the young person have additional responsibilities to look after siblings? Yes [ ] No [ ]
What does the young person’s caring role involve? (eg. personal care, moving/handling, emotional support, etc)
What impact does the young person’s caring role have on them, and how well are they currently coping with it?
Please indicatewhich level of support you feel is required from the Young Carers Project
General Support
Social/Peer Support via a Group
Specific Issue-based Group Support
Intensive 1-2-1 Support / Tick: / Reason:
Do you feel that the young carer would benefit from another service within our organisation, e.g. befriending, advocacy, family support? (If yes, please give details)
Does the young carer currently receive service input from any other statutory and/or voluntary agency?
(If yes, please provide details)
Does the young carer currently attend any other groups? (If yes, please provide details)
Any other comments or information that you think may be relevant? (e.g. family issues, cultural/religious, behavioural, bullying etc)
  1. REFERRER’S DETAILS

Name:
Designation (if applicable)
Agency (if applicable)
Address (inc postcode)
Telephone
Where did you find out about the Young Carers project
Would you/your agency meet transport costs to/from the Carers Centre? / Yes [ ] No [ ]
Would you be willing to do a joint home visit? / Yes [ ] No [ ]

Thank You for completing this form.

Please return to the postal or email address on the frontpage.

Office use only

Date:
Referral Date:
Received By:
Acknowledgement of referral sent to referrer:
Acknowledgement of referral sent to young carer and his/her family: / [ ]
[ ]

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