Young Carer Referral Form
Young Person’s Details
Full Name:......
Address:......
...... Postcode:.....
Telephone:...... Date of Birth:..Age:
Male Female Which school does the young person attend?......
Is the young person aware of this referral and can they be contacted? Yes No
Has the parent/guardian consented to this referral and can they be contacted? Yes No
Is there a current Early Help Assessment or Child Protection Plan in place? Yes No
If Yes, who is the lead practitioner? ......
Name of Parent/Guardian:......
Parent/Guardian Address:......
...... Postcode: .....
Telephone:......
Reasons for referral (please detail the condition of the person being cared for, as well as some of the caring activities that the young person is carrying out).
If this referral is regarding a young person within a family with a substance misuse problem
(Hidden Harm Project), please complete the section below.
Family member with substance misuse problem:......
Substances taken both illicit and none illicit, prescribed amounts, usage etc.
......
......
How you feel drug/alcohol use is affecting the family?Particularly, the children and young people in the family. Please give as much detail as possible:
......
......
......
......
Please give details of other agencies involved (if any)
Agency/Service / Contact Name / Contact NumberPlease give details of any known risk: ......
......
Referrer Information
Name:...... Agency:......
Designation: ...... Date of Referral:
Address:......
Postcode: ...... Telephone:....
Please return completed referrals to the postal address or email address below.
Blackpool Carers Centre |Beaverbrooks House|147 Newton Drive| Blackpool | FY3 8LZ
Tel. 01253 393748 | Fax: 01253 391616 | Email: |
Blackpool Carers Centre is a registered charity in England and Wales No. 1114558.
Registered as a company limited by guarantee in England and Wales No. 5633524.