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Aberdeenshire Carers Referral / Registration Form

Date of Referral:

I want to:

Carer Category

You are an Adult Carer if you are over the age of 18 and do not attend school

Young Carer

	Yes	No
Is under 18 years old?
Lives in Aberdeenshire?
Has an ongoing caring role for someone in their household?
Does the family recognise that the individual is a Young Carer?
Are school aware that the individual could be a Young Carer?
Is the primary Carer in the household?
Care for a parent or guardian?
Care for a sibling?
Care for more than one person?
Lives in a single parent household?
Is the Young Carer on the child protection register?
Gives consent to the referral?
Parent/Guardian gives consent to the referral?

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

Please provide details of who else lives at home / family structure:

If a Social Worker / Carer Advisor / 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:

The Young Carer's role has a direct impact upon, or affects:

Other (Please explain):

School Cluster

Name of School

Name of School Contact (Guidance Teacher / Named Person

School Contact Phone Number

School Contact Email

How did you hear about VSA?:

Carers Details

Carer Date of Birth

Carer Title

Carer First name

Carer Last name

Carer Address - Street

Carer Address - Town/City

Carer Address - Region/County

Carer Address - Postcode

Carer Telephone Number:

Carer Mobile:

Carer Email Address:

Carer Gender

Ethnicity:

Nationality:

First Language:

Marital Status:

Religion:

	Yes	No
Interpreter Required:
Interpreter Required:

GP Practice:

	Yes
Is support required for palliative care?

Reason for referral

Hold Ctrl key + click to select multiple

Please give further details on why you are looking for support in your caring role

Please provide details if you have any disabilities, illnesses and/or communication needs?:

Referrer Details

Referrer Title

Referrer First Name

Referrer Last Name

Referrer Position

Referrer Name of Organisation

Referrer Telephone number:

Referrer Email address:

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

	Yes	No
Has the referral you are putting forward been discussed with the Carer?

Please state why the Carer is unaware of the referral:

At present what support do you or your organisation provide to the Carer? :

Details of Person Being Cared For

Cared For Date of Birth

Cared For Title

Cared For First Name

Cared For Last Name

Cared For Gender

Cared For Relationship to Carer

	Yes	No
Does the Cared For live at the same address as the Carer?

Cared For Address - Street

Cared For Address - Town/City

Cared For Address - Region/County

Cared For Address - Postcode

Condition of Cared For

Other (Please provide additional information):

If you care for more than one person, please select 'Add Another Response' below.

Other Agencies/Services Involved With Family

	Yes	No	Unknown
Are there any other agencies/ services involved with the family?

Agency

Contact Person

Service Being Delivered

Risk Factors

List any risk factors identified: e.g. lone working, environment, challenging behaviour including substance abuse or pets etc

Narrative

Any additional need to know information:

Data Consent

	Yes	No
Is Carer aged 11 years old or younger?

Name of Parent/Guardian required if completing form on behalf of Young Carer

Your Privacy and How We Use Your Information

The Data Protection Act 2018 and the UK General Data Protection Regulation (GDPR) lay down rules on how services (e.g. schools, health services and voluntary services) must manage information. The Information Commissioner’s Office (ICO) is an independent regulator that protects your rights when it comes to information about you.

Registering with VSA Aberdeenshire Carers Service means your details will be held on our database and you’ll receive newsletters and mailings from us, by post and electronically (depending on your preferences), with information that may be relevant and interesting to you in your role.

Please read this statement carefully and let us know if you are happy for us to store, process and where relevant, share your personal information.

VSA will store and process information that you provide at the point of referral or at any subsequent time in a secure and sensitive manner in line with relevant data protection legislation.

This information may be used and shared with partner organisations or anonymously for reporting and monitoring purposes.

VSA Aberdeenshire Carers Service will not disclose any personal information provided with other organisations without explicit consent unless a person’s safety and well-being is at risk.

	Agree	Disagree
I confirm that I have read and understood this declaration and give permission for my personal information to be stored, processed, and where relevant, shared.

Future Communication From VSA Aberdeenshire Carers Service

Please let us know how would you like VSA to communicate with you in the future.

	Agree	Disagree
By email:

Email consent purposes:

	Agree	Disagree
By post:

Postal consent purposes:

Data Protection

The information collected on this form is recorded manually and on computer, stored securely and processed for the purpose of providing you with a support service. VSA will process your information fairly and lawfully, and in accordance with the principles of the Data Protection Act 2018. Your information will be shared with the other agencies involved in providing you with support. You have already agreed to this information being shared by signing the Consent to Share section above.

For the purposes of processing your personal information, VSA is the Data Controller you have a right to obtain details of the personal information which VSA holds about you. Such a request should be made in writing to Data.Protecton@vsa.org.uk

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Contact Information

	High	Medium	Low
Referral priority
Referral priority

	Post	Email	Phone	Mobile
Preferred Contact Method:
Preferred Contact Method: