Young Carers’ Assessment and Referral Form

Please complete one form per young person

Name of Young Carer / DOB / Age / Gender / Name of School / College

Address ______

______Postcode ______

Tel. No. ______Mobile ______

Email ______

Name of Parents / Guardian ______

Address (if different) ______

Who is being cared for (name) ______

Relationship to Young Carer ______D.O.B. of cared for ______

Condition ______

Reason for Referral:
Has a Single Assessment Framework been completed for the young person?
Does the young person have a Child in Need / Child Protection Plan?
Is the young person a Looked After Child?
Social Worker / Lead professional
Organisation
Contact Tel. No. and Email
Details of any other support / services the family receive:
Name of Person Making Referral
Agency making referral
Contact Tel. No. and Email

Are the family aware you are making this referral? Yes Is the Young Person aware? Yes

Completing this form gives us permission to hold your details on our computer system for mailing purposes, monitoring and to establish contact with Young Carers. I give permission for information to be shared with other professionals to support my family.

Name (Parent/Guardian) ______

Signature ______Date ______PTO

Further information related to being a young carer

This side must be completed by the young person or a parent / professional with the young person. Please let us know if you need support with this (please see our contact details below).

Name of Young Carer

*For the purposes of this assessment the person you care for will be referred to as your relative

Who else in your house helps to care for your relative? ______

Does being a young carer make your homework / exams /achievements / attendance in school / college / training / work difficult? No Yes

Does being a young carers make it difficult to go out with friends / to clubs / have hobbies or have free time? No Yes

Does being a young carer affect your friendships / family relationships? No Yes

Does caring ever make you worried / stressed / anxious or affect your physical health / sleep / diet / fitness / getting ill often? No Yes

How many hours of caring do you carry out on a typical:

Monday - Friday? Hours per day: ______Saturday or Sunday? Hours: ______

Do you help with personal care (bathing / toileting) / medication / lifting? No Yes

Would you like to know more about your relative's condition / needs? No Yes

§  If you answered yes to any of the above question please tell us how we or other services can help you?
§  Is there anything else you think we should know?

I give permission to share with other agencies and professionals in order to support me

I give permission to share that I am a young carer with my school

Name of young carer ______

Signature ______Date ______

PLEASE RETURN TO: YOUNG CARERS DEVELOPMENT WORKER

Battenburg Family Centre, Battenburg Avenue, Portsmouth PO2 0SN

Tel: 023 9266 1959 E-mail:

Do you consider that you have a disability under the Disability Discrimination Act definition? £ Yes £ No

£ Vision £ Mobility £ Hearing £ Other

Which of the following ethnic groups do you belong to?

Asian or Asian British

£Indian

£Pakistani

£Bangladeshi

£Other

Black or Black British

£African

£Caribbean

£Other

White

£British

£Irish

£Other

Other

£Chinese

£Other

Mixed

£White Asian

£White Black African

£White Black Caribbean

£Other