Gloucestershire Young Carers Referral Form

Charity Number 1090829 7 Twigworth Court Business Centre, Twigworth, Gloucester, GL2 9PG

CONFIDENTIAL – PLEASE DO NOT EMAIL THIS INFORMATION

Please complete all sections as there may be a delay if all the information has not been completed

Has the family agreed to this referral? Y/N Required prior to referral: parent/guardian or YC 18+
Young Carer’s Details
First Name / Last Name / Known As
Current Address
Postcode
Home telephone / Mobile –
Parent / Mobile – Young Carer
Email - Parent / Email – Young Carer
Preferred method of communication / Letter / Email
Date of Birth / Age at Referral / Gender
School or College / GP Name and Surgery
Ethnicity-Please tick box
White-British / White-Eastern European / Other White Background
Asian/Asian British-Indian / Asian/Asian British-Pakistani / Asian/Asian British-Bangledeshi
Black/Black British-Caribbean / Black/Black British-African / Chinese
Mixed-White & Asian / Mixed-White & Black Caribbean / Any other mixes background
Any other ethnic group / Not obtained/refused
Disability/Behavioural support needs of the young carer
Has the young carer had any of the following assessments
Children Act? / Y/N / CAF?
Lead professional is: / Y/N / Is in receipt of school meals? / Y/N
Information on Person/s Cared For
Name / Relationship to young carer (identify parent/guardian contact) / Date of Birth (if under 18) / Lives with young carer-Y/N
Nature of illness/disability of the cared for person/s
Physical Disability / Physical Ill Health / Mental Ill Health / Please tick
Learning Disability / Substance Misuse / Other
How does this affect them day to day and are they receiving treatment?
Additional Information
Other Household members (include Parent or Guardian)
Name / Relationship to young carer (identify parent/guardian contact) / Date of Birth (if under 18) / Has caring responsibilities? Y/N
Significant Others (eg. absent parent, foster carers, extended family, family friends etc.)
Name / Relationship to young carer / Level of contact
Does the young carer live in a single parent household? / Y/N
Significant family circumstances/safeguarding issues
Please outline in detail the reasons for your referral:
What are the child’s caring responsibilities and their needsin relation to their caring responsibilities?
What is the impact on the child of being a young carer? (eg physical, mental well being, socially, educationally etc)
What strengths and protective factors does the child have?
E.g. – good school attendance, a positive role model in their life.
Other Agencies providing support for you and your family
Name, Role and Agency / Contact details / Overview of support/services offered
Referrer’s Details
Name / Title or role / Agency
Team and Address / Contact Telephone / Email
Have you visited the family at home / Yes /No
Potential Risk factors on home visit including animals, dogs etc?
What will be your ongoing involvement with the family?
Please complete this page with the young carer or, if not possible, with the parent/guardian

MACA-YC18

The caring jobs I do

Below are some of the jobs that young carers do to help. Think about the help you have provided over the last month. Please read each one and put a tick in the box to show how often you have done each of the jobs in the last month. Thank you

Never / Some of the time / A lot of the time
1. Clean your own bedroom
2. Clean other rooms
3. Wash up dishes or put dishes in dishwasher
4. Decorate rooms
5. Take responsibility for shopping for food
6. Help with lifting or carrying heavy things
7. Help with financial matters such as dealing with bills, banking money, collecting benefits
8. Work part time to bring money in
9. Interpret, sign or use another communication system for the person you care for
10. Help the person you care for to dress
11. Help the person you care for to have a wash
12. Help the person you care for to have a bath or shower
13. Keep the person you care for company e.g. sitting withthem, reading to them, talking to them
14. Keep an eye on the person you care for to make sure they are alright
15. Take the person you care for out e.g. for a walk or tosee friends or relatives
16. Take brothers or sisters to school
17. Look after brothers or sisters whilst another adult is near by
18. Look after brothers or sisters on your own
Referrer Signature …………………………………………………Date......

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