Referral Form Young Carers Service

Young Carers Service

You can Refer young carers under 18 years

Please complete as much of the form as you can – required information in italics

We will be able to process your referral as soon as we receive this form.

Young Carer Details

Young Carers Service

First Name and Middle Name

Surname

Name of Parent Guardian

Parent / Guardian Date of birth

Current Home Address

Postcode

School / College Name

School contact person and role

School Phone Number

Is the school aware the young person is a young carer ? YN

Religion

Ethnicity

First Language

Gender (M/F) Young Carer’s Age

Date of Birth

Does the young carer have a disability or other health condition?

Email Address

Telephone Number’s

Landline

Parent Mobile

Young carer

Mobile

GP Surgery
DETAILS OF THE CARED FOR PERSON

First Name

Surname

Date of birth of cared for person

Address (if different from young carer

Relationship to Young Carer

Reason for care (eg physical disability, illness, etc)

Please list some tasks undertaken in the caring role

Approximately how long has the young carer been caring ?

Young Carers Service

Other Members of the HouseholdDate of BirthRelationship

Other Agencies Known to be involved (please tick)

Health visitorAdult Care Services

District NurseGP

Childrens’ ServicesAny Voluntary Organisation

School NurseSocial Worker

Community Mental Health TeamYouth Connexions

Family Support WorkerCAMHS

Is there an open Families First Assessment (also known as EHM)YN

How did you hear about this Service ?

Signatures Page

Parent / Guardian signature are required below :

Please sign below to consent to the information being recorded on a Carers in Hertfordshire database and for Carers in Hertfordshire to send you information.

Signature Date

Parent Name: ______

Has the young carer agreed to this referral YN

Hertfordshire County Council has a duty to identify Young carers. Carers in Herts is able to complete a Young Carer’s Registration and Assessment and store on a Herts County Council system. Please sign below if you agree to this.

Signature Date

DETAILS OF THE REFERRER

First Name / Surname
Organisation / Telephone Number
Address / Email Address
Please use the space below to explain the caring role of the young person and any other information (Please use additional sheet if required)
Referring Agency: Please give details of any actions/services you have put in place for this young carer/family.
Referrer Please Note: If you are a social worker/professional who is continuing to work with this young carer/family, would you like to receive a copy of the trips and activities information/correspondence we send to them on a regular basis? (This can sometimes encourage the young carer to respond and engage with the Service)
Yes / No

Carers in Hertfordshire is a
carer-led charity
Carers in Hertfordshire Young Carers Service:

Ensures all young carers and their families have access to information, advice and support
Provides a voice for young carers about issues that affect their lives
Raises awareness, liaises and undertakes joint work with all relevant agencies
Develops early recognition and identification
Provides free breaks and activities for young carers

Making Carers Count
Carers in Hertfordshire: A Company Limited by Guarantee
Registered Company Number 4131036 (England and Wales)
Registered Charity Number 1085491