Young Carer 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 CARER’S DETAILS
Name
Date of birth
Age
Gender
Ethnicity
School/Educational Institute
Disability (if any)
PRIMARY CONTACTS DETAILS
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
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
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 MK 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? YesNo
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? YesNo
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
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? YesNo
If no, please provide details
ANY OTHER INFORMATION
REFERRER’S DETAILS
Date of referral
Role (if applicable)
Organisation (if applicable)
Phone number
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