Parental Referral

to be completed by the parent or guardian of the young carer

Parental Referral

to be completed by the parent or guardian of the young carer

"*" indicates required fields

Barnet Young Carers is a service that supports anyone between the ages of 5 — 17 who is looking after a parent/relative with an illness, disability, mental health condition or drug/alcohol dependency.

Please complete the questions below

Name of Young Carer*

First Last

Young Carer's Date of Birth*

DD slash MM slash YYYY

School/College of Young Carer*

If Not Listed, please enter the school/college*

Please enter your postcode below and click on the Lookup Postcode button

Address of Young Carer*

City*

Postcode*

Preferred Pronouns

Young Carer's Religion*

Young Carer's Ethnicity*

Name of Cared For Person

First Last

Cared For Person's Date of Birth*

DD slash MM slash YYYY

Cared For Person's Condition*

Parent or Guardian Information (please select as appropriate)

Both Parents

Single Mother

Single Father

Foster Carer

Name of Parent/Guardian #1*

First Last

Parent/Guardian #1's Relationship to Young Carer*

Preferred Language of Parent/Guardian #1*

Parent/Guardian #1's Mobile No.*

Parent/Guardian #1's Email*

Parent/Guardian #2s Date of Birth*

DD slash MM slash YYYY

Name of Parent/Guardian #2*

First Last

Parent/Guardian #2's Relationship to Young Carer*

Preferred Language of Parent/Guardian #2*

Parent/Guardian #2's Mobile No.

Parent/Guardian #2's Email

Parent/Guardian #1s Date of Birth*

DD slash MM slash YYYY

Do you live at the same address as the young carer?*

Yes

Please enter your postcode below and click on the Lookup Postcode button

Address of Parent/Guardian*

City*

Postcode*

Do you assist in caring for the Cared For person?*

Yes

Are there any parental responsibility issues?*

Yes

If Yes, please give details*

Is the Young Carer's Emergency Contact details different from above?

Yes

Name of Emergency Contact*

First Last

Emergency Contact's Relationship to Young Carer*

Emergency Contact Details

If Other, please state*

Are there any other friends or family who provide support for the Cared For person?*

Yes

Name of Friend/Family Member*

First Last

Friend/Family Member's Relationship to Young Carer*

How do they help?*

If Other, please state*

Is there anything else that you would like your family to be supported with?*

Yes

If Yes, please give us details how we can support your family further*

Are there any medical, support or dietary concerns that we should be aware of in relation to the Young Carer (information to be used with regards to activities)? Please tick appropriate box(es)*

No Concerns

Medical Concern

Additional Support Need

Dietary Requirement of Allergy

Please give us details regarding the Young Carer(s) Medical Conditions (i.e. allergies, asthma, diabetes, heart condition, back pain etc.)*

Medications Currently Taken (please include full name, dosage and frequency)

Please give us the name of the GP Surgery, the Young Carer is registered*

Young Carer(s) Additional Need Information (i.e. anxiety, high-functioning Autism, ADHD, Learning Difficulty etc.)

Young Carers(s) Level of Support (please summarise the level of support needed to suit additional needs)

Please give us details regarding the Young Carer(s) Dietary Requirements for Participation*

Young Carers(s) Food Allergies (please summarise level of reaction and actions required, i.e. EpiPen)*

Are you currently undergoing an Early Help Assessment with an allocated Family Support Coordinator at Barnet Carers?

Yes

Is there more than one child involved in the Early Help Assessment? Please complete the details of the child(ren) in the boxes below*

Yes

Name of EHA Child #1*

First Last

Relationship to EHA Child #1*

EHA Child #1's Date of Birth*

DD slash MM slash YYYY

Name of EHA Child #2*

First Last

Relationship to EHA Child #2*

EHA Child #2's Date of Birth*

DD slash MM slash YYYY

Name of EHA Child #3

First Last

Relationship to EHA Child #3

EHA Child #3's Date of Birth

DD slash MM slash YYYY

Early Help Assessment Consent*

I give Barnet Young Carers permission to complete an Early Help Assessment on my family and understand information gathered will be stored and shared with other professionals to ensure the right support is provided.

Online Young Carers Assessments

In order to understand the young carers caring responsibilities, impact of their caring role and personal interests, we request that the young carer completes the following form so we can tailor services to their needs

Primary School Assessment an online carers assessment for young carers aged between 5-11. This can be accessed via this link.

Secondary School Assessment an online carers assessment for young carers aged between 12-17. This can be accessed via this link.

Data Consent, Media Permissions and Information Sharing – By ticking and submitting below, I give consent to -

Permission for details obtained through family and young carer assessment to be held on the BYC database & Asana

For BYC to take photographs and / or film my child for use in future publicity such as promotional literature

For BYC to talk to, refer to and pass on your details to other agencies they work with or that your family may already be involved with

I give consent for BYC to inform my child’s school that they are a Young Carer

Barnet Young Carers Activities - By ticking and submitting below, I give consent to -*

For my child(ren) to participate in BYC activities

For my child(ren) to use transportation organised for BYC activities

For any first aid or medical treatment that may be professionally recommended to be given to my child(ren) whilst attending BYC activities

Future Communication - By ticking and submitting below, I give consent to -*

Consent to receive communication via phone calls

Consent to receive communication via email

Consent to receive communication via text

Consent to receive communication via post

Consent to receive communication via social media

Consent for Young Carer to use Barnet Carers Centre Drop In service

Comments

This field is for validation purposes and should be left unchanged.