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Aberdeenshire Young Carers Service Referral Form

Date of referral

The Young Person:

If young person or parent/guardian does not consent to the referral, please explain:

Please tick Yes or No to the following questions:

	Yes	No
Does the young Carer have an ongoing caring role for someone in their household?
Are they the primary Carer in the household?
Do they care for a parent or guardian?
Do they care for a sibling?
Do they care for more than one person?
Do they live in a single parent household?

The young person cares for someone with:

Hold Ctrl key + click to select multiple

Other (Please explain):

The young person's caring role has a direct impact upon, or affects:

Hold Ctrl key + click to select multiple

Other (Please specify):

Young Carer Details

Carer Title

Carer First Name

Carer Last Name

Carer Date of Birth

Carer Gender

Carer Address

Carer Address - Street

Carer Address - Town/City

Carer Address - Region/County

Carer Address - Country

Carer Address - Postcode

Contacts

Carer House Telephone Number:

Carer Mobile:

	House Telephone Number	Mobile
Please select best number to use

School Cluster

School Attended

Name of School Contact (Guidance Teacher / Named Person

School Contact Email

School Contact Phone Number

Carer Ethnicity

Carer Preferred Language

Reason for referral

Hold Ctrl key + click to select multiple

Please give further details to why the carer is being referred for the above reason

	High	Medium	Low
Referral priority

	Yes
Support with palliative care required?

	Yes	No
Does the young carer have any disabilities, illnesses/ communications needs?

If Yes, please state:

Cared For Details

Cared For Title

Cared For First Name

Cared For Last Name

Cared For Address (if different)

Cared For Address - Street

Cared For Address - Town/City

Cared For Address - Region/County

Cared For Address - Country

Cared For Address - Postcode

Cared For House Telephone Number

Cared For Mobile

Cared For Email

	House Telephone Number	Mobile	Email
Please select best contact method to use

Relationship to young carer

What agencies/supports are in place for the cared for?

Why is the person being cared for? (Please give information on their condition, how it affects them, is it stable or variable and what they need support with, etc?)

Home Details

Who else is at home/ Family structure

	Yes	No
Does the family recognise that this young person is a young carer?
Is the young person on the child protection register?
Are there any known risks to personal safety which would be relevant to the worker who will contact or visit the family?

Supports

Who else is involved for the young person?

Professionals Involved Name Contact Number

Social Worker

Named Person

Guidance Staff

School Nurse

Health Visitor

Other

	Yes	No	Don't Know
Are school aware that the young person could be a young Carer?

If a Social Worker / FWW / Third Party Representative has contacted the school to let them know that the young carer has been referred to Aberdeenshire Carer Support Service for support, please give details:

Date contact made

Any other relevant information in support of the referral?

Referrer Details

Referrer Title

Referrer First Name

Referrer Last Name

Referrer Organisation

Referrer Job Title

Referrer Telephone Number

Referrer Email

By entering an email address here, you are agreeing to have a full copy of this referral sent to this address.

At present what support do you or your organisation provide to the young carer?

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Contact Information

	Yes	No
Is under 18 years old
Lives in Aberdeenshire
Gives consent to the referral
Parent/Guardian consents to the referral