Gloucestershire Young Carers Referral Form

Please see our website glosyoungcarers.org.uk for further guidance on making a referral.
This form must be submitted and cannot be saved and returned to at a later date.
In order to avoid delay please complete all sections as fully as possible.

Consent Information

We cannot accept referrals without parental/legal guardian’s consent for young people under 18, or the Young Persons consent if over 18.
By ticking “Yes” you confirm that you have spoken to the parent/legal guardian or young person (if over 18) and obtained their consent to share their personal information and for Gloucestershire Young Carers to hold and manage this information on their systems.

Important: Absent Parent’s/Guardian’s consent is required if the referral contains their personal information and/or information about a caring role the young person has for them.

Has the Parent/Guardian agreed to this referral?*

Has the Young Person agreed to this referral?*

Has the Parent/Guardian/Young Person (if over 18) consented for information in this referral to be held by Gloucestershire Young Carers?

Please refer to our privacy policy on our website for more information about how we look after your personal data*

Has this completed referral been shared with the parent/guardian/young person (if over 18)?*

Assessors from Gloucestershire Young Carers make determined efforts to contact parents/guardians or the young person (if over 18).
However, when we are unable to make contact, progress of the referral can be delayed.

Should the assessor be unable to make contact does the parent/guardian or young person (if over 18) give consent for Gloucestershire Young Carers to:

Contact the other agencies identified on the referral form before speaking with the parent/guardian or young person?*

Arrange to visit the young person in school before speaking with the parent/guardian/young person?*

Details of Young Person Being Referred

Pronoun

First name*

Surname*

Address line 1*

Address line 2

Town

Postal District*

Postcode*

Telephone number (If over 16)

Email (If over 16)

Date of Birth*

Gender*

Ethnic Group*

Current education or employment status*

School/college name (if relevant)

GP Surgery*

Does the young person
receive free school meals?*

Is this young person
currently on a My Plan or My
Plan +?*

Is the young person open to
social care?*

Is the young person currently
on a child protection plan?*

Is the young person currently
on a child in need plan?*

Does the young person have any disability or behavioral support needs? Are there any communication difficulties?

Please give as much detail as possible so we can ensure our assessment meets the needs of the young person.

Please tell us more about the young person and their caring role here.

(If possible, please complete this section with the young person)

What does the young person like doing? What are their hobbies and interests?

What does the young person understand about the illness/disability of the person they care for? Please tell us what words the family use at home to describe or talk about the illness/disability.*

What does the young person’s caring role involve? Please provide details of any practical and/or emotional support given i.e. shopping, lifting, household chores/paperwork, personal care, listening or comforting, and if the caring role is beyond what would be expected for their age.
Please also take into consideration other responsibilities i.e is the young person caring for other siblings, or organising and giving medication? Are they the main carer or does someone else take main responsibility and they support that person?*

Have the family and or young person already received any support or advice about their caring role?

Please include details about any agencies/professionals you are aware of currently working with the family.

Please tell us how the caring role affects the different parts of the young person’s life below

Free Time and Fun – does their caring role stop them from taking part in activities, meeting with friends or maintaining friendships?

Physical Health – does their caring role result in any physical health issues? For example aches, pains, tiredness, injuries?

Good Emotional Health – does their caring role affect their emotional health? How they feel?

Education/Employment - does their caring role affect their education/learning or employment? i.e. attendance, homework, concentration whilst at work/school

Any other additional information you wish to share with us

Parent/Legal Guardian’s details

Name (Including title)*

Relationship to young person*

Does this person live with the young person being referred?*

Is this person first point of contact?*

We require at least one method of contacting the Parent/Legal Guardian if the young person is under 18 to process this referral.
If you do not have an email or telephone number please state this in the box entering 0000 or noemail@email.com

Home Telephone No.*

Mobile Telephone No.*

Email address*

Single Parent Family?*

Are there any Communication Difficulties we should be aware of? i.e. sight/hearing/literacy/access to email.

Information about the person/s cared for

First name*

Surname*

Relationship to young person*

Do they live with the young person being referred?*

Main Disability/illness*

Is the Cared for person registered disabled?

Please tell us here information you would like us to know about how the person’s illness/disability affects them on a day-to-day basis including the names of any other illness or disability and if they are receiving treatment.*

Do you want to add another person?

Other Household Members

Please tell us about other people who live with the young person in the box below. Include the relationship to the young person and date of birth if under 24. Tell us if any of these people also have a caring role and provide contact details if a parent/guardian.

Living Arrangments

People in household

Significant Others

Please tell us about any other significant people in the young persons life who support their caring role and DO NOT live with them.

This could be grandparents, other family members, neighbours or friends. Please tell us how much contact they have with this person and how they support them.

Referrers Details (person completing this form)

Name*

Title/Job Role (if relevant)

Agency (if relevant)

Team Name (if relevant)

Address (if different from Young Person)

Telephone No.*

Email*

What will be your ongoing involvement with the family?

Have you visited the family at home? If yes how recently?

Are there any significant risk factors, family and/or safeguarding issues we should be aware of before completing the young person’s assessment and visiting the home?
For example, has there been recent bereavement, loss, domestic violence? Are there animals at the property, smokers, or other people at the property we should be aware of when visiting? (If No please state none known)*

Where did you hear about Gloucestershire Young Carers?*

Date*