Action for ChildrenReferral form

Harrogate & Craven Young Carers Service

Action for Children

Harrogate Young Carers

Conyngham Hall Business Centre

Knaresborough

North Yorkshire

HG5 9AY

Tel: 01423799135

Email:

It helps us to offer the best service possible if we have as full a picture as you are able to give of all the family members and issues affecting them.

Please complete all sections possible

PLEASE USE A SEPARATE FORM FOR EACH CHILD BEING REFERRED AS A YOUNG CARER

DETAILS OF PERSON MAKING REFERRAL

NAME / REFERRAL DATE
ADDRESS / ROLE & ORGANISATION
TELEPHONE / EMAIL
NAME OF LEAD PROFESSIONAL (e.g.CAF) / LEAD PROFESSIONAL’S CONTACT NUMBER

DETAILS OF CHILD OR YOUNG PERSON BEING REFERRED

NAME / DATE OF BIRTH
MALE OR FEMALE / RELIGION
ADDRESS & POST CODE / HOME PHONE PARENT MOBILE OWN MOBILE
OTHER
CHILD’S FIRST LANGUAGE / PARENT’S FIRST LANGUAGE
INTERPRETER OR SIGNER REQUIRED? / IF YES, HAS THIS BEEN ARRANGED?
ETHNICITY OF YOUNG PERSON
DOES THE CHILD/YOUNG PERSON HAVE A DISABILITY? DETAILS OF ANY SPECIAL REQUIREMENTS (FOR CHILD AND/OR PARENT) EG WHEELCHAIR USE, DIETARY NEEDS, MEDICAL NEEDS .
HAVE YOU SEEN THIS CHILD/YOUNG PERSON AS PART OF THE REFERRAL? IF YES WHAT ARE THE REASONS FOR THE REFERRAL

CURRENT FAMILY/HOME SITUATION (E.G. FAMILY STRUCTURE, WHO THE CHILD/YOUNG PERSON LIVES WITH, HOUSEHOLD MEMBERS, SIBLINGS, SIGNIFICANT OTHER FAMILY MEMBERS/ADULTS ETC) please identify with * who resides in the family home. Please add contact details if not living with the child/young person.

First name and family name (add any useful pervious names) / Address
Use * unless not same as Young Carer / Date
of birth / Relationship to child/young person / Does this person have parental responsibility? / Place of Employment or School/Nursery

DETAILS OF THE PERSON BEING CARED FOR (delete, tick or highlight as appropriate)

Please expand and numerate (see “the caring role” below) if there is more than one.

Does the cared for person live with the child?YESNO

Does the cared for person have a terminal illness?YESNO

Is the person being cared for a single parent?YESNO

Is the child the only or lead home based carer?YESNO

Are agencies or others also supporting with care?YESNO

IMPACT OR CARING

Is school attendance being affected?

If YES please explain

Is school achievement being affected?

Please give details

Is the child being socially isolated?

Please give details

SERVICES WORKING WITH THE CHILD/YOUNG PERSON (E.G. have they had a CAF, Child in need assessment, do they have a school mentor…)

SERVICE / DETAILS / TELEPHONE NUMBER
UNIVERSAL / GP
SCHOOL ATTENDED include details of CAF if in place.
EDUCATION or TRAINING PROVISION: including PRU/ home tuition/ day release/ specialist teaching
OTHER SERVICES / SPECIALIST SERVICES e.g. CAMHS
CHILDREN’S SOCIAL CARE
e.g. Child in need assessment

THE CARING ROLE (Please numerate if there is more than one)

Name of person being cared for and their relationship to the Young Carer:
Illness/disability/condition of person being cared for:
Details of young carer’s responsibilities:
What outcomes do you/the family/the young carer hope the service can achieve for the young carer?
Has the cared for person received a community care, social worker or occupational therapist assessment?
Please detail any support from the statutory or voluntary agencies received by the cared for (social worker, CPN etc..) or the family e.g. family worker following family assessment.
Are there any housing services/issues that might affect the young carer and family?

GENERAL DEVELOPMENT OF THE YOUNG CARER

General Health / Is the young carer’s health good?
If no, please give details.
Physical Development / Does the young carer have any physical or mobility problems?
If yes, please give details.
Speech, Language and Communication / Does the young carer have any communication problems?
If yes, please give details below indicating how the child or young person communicates.
Behaviour Development / Are they any behavioural problems?
If yes, please give details including any management strategies used.
Self Care skills and independence / Does the young carer need help with personal care or dressing?
If yes, please give details below.
Interests / Is the young carer currently attending any leisure activity/group/out of school club etc? If yes, please give details below.
Other information- please provide any other information you feel is relevant to this referral

AGREEMENT

CHILD/YOUNG PERSONS COMMENTS

Do you agree with the referral being made?
If no, could you tell us why please?
Signed:

PARENT OR CARERS COMMENTS

Do you agree with the referral being made?
If no, could you tell us why please?
Signed:

PROFESSIONAL INFORMATION

Are there any Health & Safety issues that we need to be aware of prior to undertaking an initial visit to the family?
If yes, please give further details, e.g. dogs, smoking, risk of aggression.
Please tell us how you heard about our service
Referrer’s signature / Date