Young Carers Referrals

Young person details
Details of the young person who performs caring role.

Name of young person*

Address of young person*

Locality that family fall under if known

Date of birth*

Contact details for young person*

Gender
MaleFemaleOther

Preferred Language

Which school or college is the young carer currently attending?*

Parent/Carer details
Details of the Parent/Carer/Guardian

Parents name*

Parents address*

Parents phone number*

Parents preferred language

Who does the young person live with?

Details of the caring role

Name of person 'cared for'

Reason for care*

Relationship of 'cared for' person to child/young person

Family circumstances; strengths & challenges

Details of the care the young person provides *

Details of organisations supporting the young carer and their family

Has an EHA been completed for the Young Carer and their family?
YesNo

If so, is it currently active and who are the professionals involved with the family?

If not, why not?

Has a North Tyneside Council Young Carers Needs Assessment been completed for this Young Carer and logged with the local authority?
YesNo

If yes to the above question, by whom?

Does the young person have a social worker?
YesNo

Please give name

Referrers details

Name of referrer*

Organisation

Role

Contact number*

Email address of referrer

Is it safe to visit the family home/visit alone?*
YesNo

Please indicate how you have come to the above assessment

Please explain the impact that you feel the young persons caring role is having on their life

What support are you hoping to get from the Young Carers Project for the Young Carer?

Are the parents/ carers aware of this referral?
YesNo

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