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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?

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

Carers FIRST

Michael Gill Building, Tolgate Lane,
Strood, Rochester
Kent ME2 4TG

Registered Company : 4144820

Registered Charity : 1085430

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Carers FIRST is funded by local authorities, trusts and grants. We also rely on private donations to run additional activities which give carers the opportunity to have a break from their caring role. If you are interested in fundraising for Carers FIRST, please email us:

hello@carersfirst.org.uk

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Need Some Help?

You can contact us on the following phone numbers:

If you look after someone and would like to find out more information about Carers FIRST please contact us at:

Tel: 0300 303 1555

Email: hello@CarersFIRST.org.uk

If you are a professional and would like to refer a carer to Carers FIRST for support please contact us at:

Tel: 0300 303 1555 (option 2)

Email: referral@CarersFIRST.org.uk

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