Young Carers Project Referral Form
Carers FIRST is an independent, charitable organisation supporting and helping people who look after a relative or friend. Please complete this form if you would like to refer a young person for support who lives in, or looks after someone who lives in Medway. Please ensure the person you are completing this form for is aware of the referral. Please provide us with as much information as possible, once processed our Young Carer Team will be in contact with the family to organise a home visit. If you require more urgent support please call us on 0300 303 1555. Thank you.
1 Referrer's full name
2 Organisation referrer works for
3 Referrer's contact details
please provide us with a telephone number & email address
4 Name of Young Carer
5 Young Carers date of birth
6 Young Carers address
7 Parent/ guardians name
8 Contact telephone numbers
9 Parent/ guardians email address
10 Young Carers email address
11 Does the Young Carer have a diagnosis of any special or additional needs?
If yes please detail
12 School details
Including; school name, year and any attendance issues.
13 Reason for referral
14 Name of the person who is cared for
15 Date of birth of the person who is cared for
16 Relation of the Young Carer to the person who is cared for
17 Health condition of the person who is cared for
18 Any further information, including any safeguarding information we need to be aware of.
Is there any important information that may be pertinent to the Support Worker when visiting the home assessment, that you are aware of? If necessary please contact the Young Carer Team directly regarding this
19 Is the Young Carer aware of this referral?
Yes
No
20 Are the parents/ guardians aware of this referral and have given consent for this information to be shared?
Yes
No
21 Does the Young Carer have significant difficulties with regards to any of the following areas?
Please mark all that apply
Child Protection
Personal Behaviour
Family Breakdown
Housing
Finances
Mental Health
Self Esteem/ Confidence
Physical Health
Education and School
Forming Friendships
Normal Social Contact
Isolation
Person Free Time/ Playtime