Young Carers & Young Adult Carers Project

Referral Form

Please write clearly and complete all fields

YOUNG PERSON’S DETAILS
Title / Mr / Mrs / Master / Miss / Other: ______(please specify)
First Name
Surname
Date of birth (DD/MM/YYYY)
Address
Postcode
Home Telephone / Mobile Number
Email Address
Ethnicity / White - BritishWhite - EuropeanWhite - IrishWhite - TravellerWhite - Other White BackgroundAsian Or Asisian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - OtherAsian Or Asian British - PakistaniAsian Or Asian British - AfricanBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Othe Black BackgroundMixed - Other Mixed BackgroundMixed - White and AsianMixed - White and Black AfricanMixed - White and Black CaribbeanOther Ethnic GroupPrefer Not To Say / Religion / BuddhistChristianHinduJehovah's WitnessJewishMuslimSikhNo-ReligionPrefer Not To Say
First Language
Education / Employment / Attends School / Attends College / Attends Uni / Home Education /
Full Time Employed / Part time Employed / Training / Other: ______
School/College/Uni Name
SEN Status / Yes / No
Reason for Referral: Please provide as much detail as possible.
Does the young person have a Child Protection or Child in Need Plan in place?
Child Protection / Child in Need Plan
If ‘Yes’, please give name and contact details of Social Worker:
Is the young person looked after? e.g. foster care
Yes / No
Does the young person have a disability?
Yes / No
If ‘Yes’, please give details:
Are there any additional communication needs?
Yes / No
If ‘Yes’, please give details
DETAILS OF PERSON(S) WITH CARE NEEDS
Title (Mr, Mrs, etc) / Full Name / Relationship to Young Person / Date of Birth / Condition
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
FAMILY INFORMATION
Mother/Guardian’s Full Name
Telephone/Mobile Number
Father/Guardian’s Full Name
Telephone/Mobile Number
Email Address
Other adults at home / Title (Mr, Mrs, etc) / Full Name / Relationship
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
Other children at home / Full Name / Date of Birth
Extended family and their involvement / Yes / No
If ‘Yes’, please provide name and details / Title (Mr, Mrs, etc) / Full Name / Relationship
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
MrMasterMissMrsMsDrProfOther / MotherFatherPartnerBrotherSisterFoster CarerGrandparentOther Family MemberFriendStep-MotherStep-Father
Does the family have access to transport? / Yes / No
OTHER AGENCY INVOLVEMENT
Agency Name / Agency Name
Contact Name / Contact Name
Tel. Number / Tel. Number
If multiple agenices are involved, please provide details in Additional Information or on a separate sheet.
Is there any other information about the family which would be helpful to support this referral? (e.g. domestic violence, animals, etc.). Continue on further sheet if necessary.
REFERER’S DETAILS
Full Name
Organisation
Tel. No.
Email Address
Referral Date
How did you hear about us? / Family Member Family FriendWord of MouthColleagueGoogle / WebsearchMailingLeaflet through the doorLeaflet in LibraryLeaflet in GP PracticeLeaflet elsewhereInformation elsewhereCarer Awareness Event - GP SurgeryCarer Awareness Event - AddenbrookesCarer Awareness Event - P'boro Carers CentreCarer FriendCarer Awareness Event - Cambs OtherP'boro Community Drop InNewspaper Or Mag ArticleRadioAdvert in NewspaperAdvert on InternetSocial MediaAlready Known

Consent for information sharing to support this referral

  • I/we understand the information that is recorded on this form and that it will be shared and used for the purpose of providing services to the child/young person.
  • I/we give consent to the involvement of the identified Service.
  • I/we am/are aware of this referral.

Parent/ Guardian’s Name
(if appropriate)
Signature of Parent/Carer /
______
______/
Date
______
Young Person’s Name
(if appropriate)
Signature of Young Person /
______
______/
Date
______

Please return completed form to:

Email:

OR

Post: YC/YAC Referral

Carers Trust Cambridgeshire

4 Meadow Park

Meadow Lane

St Ives

Cambridgeshire

PE27 4LG

OFFICE USE ONLY:
Date received:
Passed to:
Collected Date:
Additional Information

G:\ALL-Data\Young Carers\Joint CTC & CTP\Forms_Final\YC-YAC Referral Form.doc1