Referral Form

(for young person being referred to project)

Full Name ______
Address______Postcode ______

Tel/mobile______Email______

D.O.B______Age _____ Male/Female (delete as appropriate)

School attending (if applicable) ______

Who is a Young Carer? A young carer is a child or young person (up to the age of 18) whose life is affected by looking after someone with a disability or long term illness.The person they care for may be a parent, sibling, another family member or a friend and may not necessarily live in the same house as them. The care they give may be practical, physical, and emotional. It is without pay or recompense and can vary in length and complexity.The terms "disability" and "long-term illness" do not mean just a physical disability or illness, but also cover for example, mental illness, learning disability, substance misuse, frailty or old age. Their caring role may also be prohibiting them from accessing the same opportunities as other young people their age.
If you are unsure whether a young person fits the criteria for being a young carer, please contact Joanne or Marion in confidence 01851 822 713/ 822 714

About the caring role

Who do they help to care for? ______

What is the illness/disability of person they care for? ______

______

What are the main caring responsibilities for this young person?

Is the young person aware of this referral form & can they be contacted? Yes/ No

(If not, please make young person aware of this referral)

If they are under 16, has the parent/guardian consented to this referral?Yes/ No

Can their parent/guardian be contacted? Yes/ No

Parent/guardian name ______

Parent/guardian address (if different from above)______Postcode______Tel/mobile______

Please give details of other agencies (if involved)

Agency/Service / Contact Name / Contact Number

Please give details of why you have referred this young person to the Pointers Young Carers Project and what their main needs are:

Referrer Information:

Name ______Agency ______

Job Title ______Date of referral______

Tel.______Email______

Address______

______

Where did you hear of us?(Please tick box)

Agency School/ Further Education Leaflet

Training/Awareness raising session Word of mouthWebsite

Other, please specify______

Office Use Date of receipt/stamp

Please return this form to:

Pointers Young Carers,Pointers Youth Centre,

14-16 North Beach Street, Stornoway, Isle of Lewis HS1 2XJ

Telephone No: 01851 822 713/ 01851 822 714, E-mail: