Please note: There will be a waiting list for any new referrals made from Wednesday 14th March 2012, which will be reviewed on the Week Commencing Monday 9th April 2012

Young Carers Referral Form

Read the guidelines for referrers before completing this form Please Note: Hartlepool Young Carers Project believe that all Carers who use the services we provide should have access to the information written about them, including this form. If you wish to share information that is confidential to the agency only and should not be shared with the Carer then please send this in a separate email to: lisa.cartwright@hartlepoolcarers.org.uk

ALL SECTIONS OF THIS FORM MUST BE COMPLETED OR THE APPLICATION WILL BE REJECTED

• Referrer Information
• Name:
• Date:
• Agency or relationship to the young person:
• Address:
• Postcode:
• Telephone No:
• When are the best times for you to be contacted:
• E-mail:
• How did you find out about our service?:

• ---

• Information about the young person you are referring to us
• Name:
• Date of birth:
• Age at date of referral:
• Gender:
• Address:
• Postcode:
• Telephone No:
• Cultural / Religion information:
• Ethnic Origin:
• Language:
• Parent or Guardians name:
• Parent or Guardians Phone Number:
• School Name:
• School Phone Number:
• School Address:
• GP Name:
• GP Address:
• Is the young person aware that you are making a referral to us? Yes Yes
• Referrals will only be accepted if the young person's parent or guardians are aware that you are making a referral to us. Please confirm this by ticking this box:
• Has a CAF been completed?: Yes No
• Are they the main Carer in the household?: Yes No
• Is the young person a young carer? Yes No
• Do they care for a parent or guardian?: Yes No
• Do they care for a sibling?: Yes No
• Do they care for more than one person?: Yes No
• Do they live in a single parent household? Yes No
• Please choose form the following conditions that best describes the person you care for: Chronic or severe ill-health? Mental health problems? Disability (physical, sensory or learning)? Drug and or alcohol problems?
• Does the young person have significant difficulties with regard to any of the following areas: Housing Personal Behaviour Family Breakdown Friendship & Social Contact? Medication Self-esteem and Confidence Mental Health Physical Health Education and School Child Protection Child In Need Family Breakdown Allergies Personal free-time/playtime?
• If the young person is not a young carer or has any significant difficulties please detail to us why you are making this referral
• Describe the Young Carers current situation, the roles that they undertake and the circumstances of the person or persons they care for
• The name(s) of the person(s) being cared for:
• Please provide the name and contact details of any other agencies working with the young person:
• Please provide the name and contact details of any agency working with the cared for person:
• Risk Assessment
• Please identify any risks that may be associated with making visits to the home environment.
• Referrers Name Confirmation:
• Hartlepool Young Carers adopt a Think Family approach and I understand that by signing this form I have given my permission for Hartlepool Carers to share information with other agencies in respect of the whole family
• Please enter the code below in order to submit the form. (Cookies must be enabled on your computer)

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