SCS

CHILDREN’S SERVICE - FLEXIBLE SHORT BREAKS FOR CARERS

REQUEST FOR A Carer Break ONE-OFF DIRECT PAYMENT

Complete this form and send it with your:
CAF / Early Help Assessment,or your
Carer’s Assessment.

Contact details of person making request:

Applicant’s Name

/ Job Title
(SW, FSW, Nurse, GP, Teacher, Carer support worker)

Work/team Name & Address

/ Telephone Number
e-mail if available

Details of the child who has a disability:

Child’s
Surname / Child’s
Forename
Child’s Date of birth. / This box for Office use only:
Child’s address / This box for Office use only:

Details of the carer here: NB Only use this form for carers over 16 yrs of age.

Carer / parent
Surname / Carer / parent
Forename
Address / Telephone number

FLEXIBLE SHORT BREAK

(It is anticipated that money would be used within one year or less from payment date)

Start Date

When is the payment needed? / End Date
Month in which you anticipate the money would be used up?

How much are you applying for £

Guidance notes:
Write in the amount that is required. One payment per carer per financial year. Applicant and or Disabled child must be a Surrey Resident. This is a discretionary payment.
Application process:
External applications are dealt with monthly. Applicants will be informed of the result of the application as soon as possible after it has been considered. The carer will also be sent a letter advising them of the outcome of the application. If a payment can be made, the carer will be required to send Surrey County Council details of their bank account so that an electronic payment can be made. It can take up to 3 weeks for payments to reach the carer after Surrey County Council have received the carers’ bank account details.
Available amount: Requests above £500 are unlikely to be considered.

Write here a brief description of the reason why a break is required and a description of intended use of the money if it were to be approved.

Applications must be based on an assessment of need.
Please indicate below which type of assessment has been carried out and attached to this application.

Applicants working with children should send in Common Assessment Framework CAF & may opt to send a Carer’s assessment too if one is available.

Enclosed :
Delete as required CAF/Early Help Assessment / Carer’s assessment

NOTE

By submitting this request you confirm that

The carer is aware of this application and has consented to his/her information as detailed above being shared with the teams that will process the application.

The carer also understands that if the application is successful the carer will need to provide details of a suitable bank account. Surrey County Council make secure payments by electronic transfer into the carer’s bank account and are unable to issue cheques.

The carer understands that he or she will be required to send Surrey County Council brief details to confirm how they have spend the money within a given period of time.

Application Completed by / Sign here: / Date of request

Scs form part b (Surrey Short Break Team use only)

Application received by / Name: / Date received
Carer’s name / Child’s name
Approval decision / Yes in full
Yes in part – how much £
Not approved / Date:
Budget code to use:
Decision made by: / Name
Details of person who will deal with the administration of this application. / Surrey Short Break Team / Name
Team
Task / Date completed
CC of decision sent to Childdps
Notify Carer and applicant of decision.
If approved :
send one-off DP agreement letter to carer
CC to childdsp
CC to applicant /external professional
If not approved:
Send standard letter
Cc to childdps
CC to applicant
Bank details received from carer
Bank details sent to finance (BACS form)
Payment made by requisition
Return request sent by Childdps
Return received.

2015 One Off Carers Break Direct Payment Request Form