Young Carer Referral Form (5-18years)

Northamptonshire Carers Young Carer Referral

Referral Date*

Surname*

Forename(s)*

How to say your name - e.g. Ian is EE-yun*

Preferred to be known as

Gender*

Address*

Town*

Postcode*

Local Authority*

Date of Birth*

Main Telephone No.*

Mobile Telephone No.

E-mail*

Ethnic Group of Young Carer*

GP Practice

School/College*

Is the family aware of referral?*

Can the Carer be Contacted (We need to have this consent before contacting families)*

Name of Parent to contact on behalf of Young Person?*

Young Carer Type*

Types of Care being provided:

Providing intimate care i.e. washing, bathing, toileting, etc

Providing childcare, helping with siblings

providing 'significant' emotional support

Dressing

Helping with Mobility

Interpreting/Communication

Nursing Tasks

Escorting or staying with someone to keep them safe

Crisis/ Alerting Emergency Support

Please Provide as much information as possible to support your referral. This helps us to prioritise for support prior to worker allocation: Please include an explanation of the care provided by the Young Carer, if this includes Emotional support state in*

Cared-For Person Information:

Surname*

Forename(s)*

Carer's relationship to dependant*

Date of Birth*

Ethnicity*

Main Disability*

Illness / Disability Further Details*

Details about a second Caree (if applicable)

Surname

Forename(s)

Carer's relationship to dependant

Date of Birth

Ethnicity

Main Disability

Illness / Disability Further Details

Are there any known safeguarding concerns for this family?*

Safeguarding category*