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
Date of birth
Disability (if any)
PRIMARY CONTACTS DETAILS
Main phone number
Details of family members living in family home
Home address (must include postcode)
GP Surgery and contact information
Has the Parent/Guardian’s consent been given but unable to sign the form? (please tick)
Please state reason for this
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?
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
Is there evidence of, or a history of the following risks associated with the young person?
A risk to themselves
A risk to others
If a risk to others, please state who
Is there evidence of, or a history of, the following risks associated with this household?
Behaviour towards professionals
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
Date of referral
Role (if applicable)
Organisation (if applicable)