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 children and young people between the ages of 5 — 17 and 18 – 25 who supports someone else (parent, sibling, other relative) on a daily basis who can't get by without their support and who might be affected by an illness, disability, mental health condition or substance misuse issue.

Regardless of the level of care provided, Barnet Young Carers supports children and young people who feel impacted by their caring responsibilities in their daily life (education, social life, physical and psychological wellbeing).

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*

Is the school aware that your child is a Young Carer?*

Yes

Do you give consent for Barnet Young Carers to inform the school that your child is a Young Carer?*

Yes

Schools have a duty of care to Young Carers

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

Address of Young Carer*

City*

Postcode*

Gender of Young Carer

If Other, please state*

Preferred Pronouns

Young Carer's Religion*

Young Carer's Ethnicity*

How many people does the Young Carer care for?*

Name of Cared For Person #1

First Last

Cared For Person #1's Date of Birth*

DD slash MM slash YYYY

Cared For Person #1's Condition*

Name of Cared For Person #2

First Last

Cared For Person #2's Date of Birth*

DD slash MM slash YYYY

Cared For Person #2's Condition*

Name of Cared For Person #3

First Last

Cared For Person #3's Date of Birth*

DD slash MM slash YYYY

Cared For Person #3's Condition*

Name of Parent/Guardian #1*

First Last

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

Is an interpreter required - Parent/Guardian #1?*

Yes

If Yes, please state the language required*

Parent/Guardian #1's Mobile No.*

Parent/Guardian #1's Email*

Is there a second parent/guardian associated with the Young Carer?*

Yes

Name of Parent/Guardian #2*

First Last

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

Is an interpreter required - Parent/Guardian #2?*

Yes

If Yes, please state the language required*

Parent/Guardian #2's Mobile No.*

Parent/Guardian #2's Email*

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*

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

EHCP (Education , Health and Care Plan)

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)

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)*

Details regarding EHCP (Education , Health and Care Plan)*

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

Is the GP aware that your child is a Young Carer?

Yes

Do you give consent for Barnet Young Carers to inform your GP Surgery that your child is a Young Carer?

Yes

GPs have a duty of care to Young Carers

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.

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

Has the young carer's assessment been completed?*

Yes

Please Note:
Submitting this form does not guarantee spaces for additional services which may have a waiting list and separated referral forms are required for some services.

Name

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