Professional Referral Form to be completed by a Professional wishing to refer a Young Carer Professional Referral Form to be completed by a Professional wishing to refer a Young Carer "*" indicates required fields Step 1 of 4 - Professional Referrer's Details 25% 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 Professional* DrMissMrMrsMsProf.Rev. Prefix First Last Job Title of Professional* Organisation of Professional* Contact No. of Professional*Email of Professional* Please enter your postcode below and click on the Lookup Postcode button Address of Professional City Postcode How did you hear about us?*-Please select from options-WebsiteColleagueProfessional ForumLeafletOtherIf Other, please state* Are you wishing to refer more than one Young Carer?* Yes No If so, please indicate how many Young Carers you would like to refer*-Please select from options-TwoThreeName of Young Carer #1* First Last Age of Young Carer #1 Young Carer #1's Date of Birth DD slash MM slash YYYY Gender of Young Carer #1*-Please select from options-MaleFemaleNon-binaryEthnicity of Young Carer #1-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Ethnic GroupUnknownParent/Guardian Name* First Last Parent/Guardian's Email Parent/Guardian's Mobile No:Parent/Guardian's Home Phone No:Relationship to Young Carer #1*-Please select from options-MotherFatherGuardianFoster CarerDoes Young Carer #1 have their own contact details?* Yes No Do not know Email Young Carer #1 Young Carer #1's Mobile No:Please enter your postcode below and click on the Lookup Postcode button Address of Young Carer #1 City Postcode School/College of Young Carer #1*-Please select from options-AkivaAlexandra PalaceAlexandra Park SchoolAll Saints CE N20All Saints CE NW2Anunciation JuniorArcher AcademyArk Pioneer AcademyAshmoleAvanti House (Stanmore)AylwoodBarnet College (Barnet and Southgate)Barnfield PrimaryBeit ShvidlerBell LaneBentley Wood HighBishop DouglassBlessed Dominic Primary SchoolBroadfields PrimaryBrookland Junior SchoolBrooklands InfantsBrunswick Park JMIBushey ManorCanons HighChalgroveChilds HillChristchurchChrist's CollegeChurch Hill SchoolCity & IslingtonClaremont PrimaryColdfallColindale Primary SchoolComptonCoppetts WoodCopthallCourtlandCromerCromer RoadDame Alice OwensDanegroveDeansbrookDollisEast BarnetEdgware InfantsEdgware JuniorEgerton Rothesay (Berkhamsted)Elstree Screen ArtsFairwayFern HouseFinchley CatholicFortismereFouldsFriern BarnetFrith ManorGarden SuburbGoldbeatersHaberdashers' Aske's for BoysHaberdashers' Aske's School for GirlsHampstead SchoolHasmonean High schoolHasmonean PrimaryHatch End HighHendonHenrietta BarnettHertswood Academy (Borehamwood)HighgateHighgate PrimaryHollickwoodHolly ParkHoly TrinityHome schooledHydeIslamzeJapanese school, ActonJCOSSJewish Free SchoolKingsburyKingsgate PrimaryLivingstoneLondon AcademyLoreeto College St AlbansLyonsdownManorsideMartinMathilda Marks KennedyMenorah Primary NW11Mill Hill CountyMillbrook ParkMonken Hadley CE PrimaryMoss HallNEETNorth London InternationalNorthgateNorthsideNot in schoolOak LodgeOakhillOrionOsidgeOur Lady of LourdesOur Lady of MuswellParkfieldPavilion Study CentreQ.E.GirlsQE BoysQueenswellRimonSacred HeartSaracensSouthgateSt AgnesSt Alban's GirlsSt Andrew's (and St Andrew the Apostle)St Andrew's CESt James' CatholicSt John's CE N11St John's CE N20St Joseph's RCSt Mary's & St John'sSt Mary's CE EN4St Monica'sSt Paul's N11St Paul's NW7St VincentStanmore CollegeSummersideSunnyfieldsThe ComptonThe HydeThe MountThe Orion SchoolTotteridge AcademyTrent SchoolTudorUnderhillWatling (Watling Park)Wessex GardensWestminster CityWhitefieldWhitings HillWolfsten HillelWoodcroft PrimaryWoodridge PrimaryWren AcademyDo not knowNot listedYear Group of Young Carer #1-Please select from options-Year 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Do not knowPlease enter the school/college Young Carer #1 attends* Name of Young Carer #2* First Last Age of Young Carer #2 Young Carer #2's Date of Birth DD slash MM slash YYYY Gender of Young Carer #2*-Please select from options-MaleFemaleNon-binaryEthnicity of Young Carer #2-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Ethnic GroupUnknownRelationship to Young Carer #2*-Please select from options-MotherFatherGuardianFoster CarerDoes Young Carer #2 have their own contact details?* Yes No Do not know Email Young Carer #2 Young Carer #2's Mobile No:Young Carer #2's Home Phone No:Does Young Carer #2 live at the same address? Yes No Please enter your postcode below and click on the Lookup Postcode button Address of Young Carer #2* City* Postcode* School/College of Young Carer #2*-Please select from options-AkivaAlexandra PalaceAlexandra Park SchoolAll Saints CE N20All Saints CE NW2Anunciation JuniorArcher AcademyArk Pioneer AcademyAshmoleAvanti House (Stanmore)AylwoodBarnet College (Barnet and Southgate)Barnfield PrimaryBeit ShvidlerBell LaneBentley Wood HighBishop DouglassBlessed Dominic Primary SchoolBroadfields PrimaryBrookland Junior SchoolBrooklands InfantsBrunswick Park JMIBushey ManorCanons HighChalgroveChilds HillChristchurchChrist's CollegeChurch Hill SchoolCity & IslingtonClaremont PrimaryColdfallColindale Primary SchoolComptonCoppetts WoodCopthallCourtlandCromerCromer RoadDame Alice OwensDanegroveDeansbrookDollisEast BarnetEdgware InfantsEdgware JuniorEgerton Rothesay (Berkhamsted)Elstree Screen ArtsFairwayFern HouseFinchley CatholicFortismereFouldsFriern BarnetFrith ManorGarden SuburbGoldbeatersHaberdashers' Aske's for BoysHaberdashers' Aske's School for GirlsHampstead SchoolHasmonean High schoolHasmonean PrimaryHatch End HighHendonHenrietta BarnettHertswood Academy (Borehamwood)HighgateHighgate PrimaryHollickwoodHolly ParkHoly TrinityHome schooledHydeIslamzeJapanese school, ActonJCOSSJewish Free SchoolKingsburyKingsgate PrimaryLivingstoneLondon AcademyLoreeto College St AlbansLyonsdownManorsideMartinMathilda Marks KennedyMenorah Primary NW11Mill Hill CountyMillbrook ParkMonken Hadley CE PrimaryMoss HallNEETNorth London InternationalNorthgateNorthsideNot in schoolOak LodgeOakhillOrionOsidgeOur Lady of LourdesOur Lady of MuswellParkfieldPavilion Study CentreQ.E.GirlsQE BoysQueenswellRimonSacred HeartSaracensSouthgateSt AgnesSt Alban's GirlsSt Andrew's (and St Andrew the Apostle)St Andrew's CESt James' CatholicSt John's CE N11St John's CE N20St Joseph's RCSt Mary's & St John'sSt Mary's CE EN4St Monica'sSt Paul's N11St Paul's NW7St VincentStanmore CollegeSummersideSunnyfieldsThe ComptonThe HydeThe MountThe Orion SchoolTotteridge AcademyTrent SchoolTudorUnderhillWatling (Watling Park)Wessex GardensWestminster CityWhitefieldWhitings HillWolfsten HillelWoodcroft PrimaryWoodridge PrimaryWren AcademyDo not knowNot listedYear Group of Young Carer #2-Please select from options-Year 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Do not knowPlease enter the school/college Young Carer #2 attends* Name of Young Carer #3* First Last Age of Young Carer #3 Young Carer #3's Date of Birth DD slash MM slash YYYY Gender of Young Carer #3*-Please select from options-MaleFemaleNon-binaryEthnicity of Young Carer #3-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Ethnic GroupUnknownRelationship to Young Carer #3*-Please select from options-MotherFatherGuardianFoster CarerDoes Young Carer #3 have their own contact details?* Yes No Do not know Email Young Carer #3 Young Carer #3's Mobile No:Young Carer #3's Home Phone No:Does Young Carer #3 live at the same address?* Yes No Please enter your postcode below and click on the Lookup Postcode button Address of Young Carer #3* City* Postcode* School/College of Young Carer #3*-Please select from options-AkivaAlexandra PalaceAlexandra Park SchoolAll Saints CE N20All Saints CE NW2Anunciation JuniorArcher AcademyArk Pioneer AcademyAshmoleAvanti House (Stanmore)AylwoodBarnet College (Barnet and Southgate)Barnfield PrimaryBeit ShvidlerBell LaneBentley Wood HighBishop DouglassBlessed Dominic Primary SchoolBroadfields PrimaryBrookland Junior SchoolBrooklands InfantsBrunswick Park JMIBushey ManorCanons HighChalgroveChilds HillChristchurchChrist's CollegeChurch Hill SchoolCity & IslingtonClaremont PrimaryColdfallColindale Primary SchoolComptonCoppetts WoodCopthallCourtlandCromerCromer RoadDame Alice OwensDanegroveDeansbrookDollisEast BarnetEdgware InfantsEdgware JuniorEgerton Rothesay (Berkhamsted)Elstree Screen ArtsFairwayFern HouseFinchley CatholicFortismereFouldsFriern BarnetFrith ManorGarden SuburbGoldbeatersHaberdashers' Aske's for BoysHaberdashers' Aske's School for GirlsHampstead SchoolHasmonean High schoolHasmonean PrimaryHatch End HighHendonHenrietta BarnettHertswood Academy (Borehamwood)HighgateHighgate PrimaryHollickwoodHolly ParkHoly TrinityHome schooledHydeIslamzeJapanese school, ActonJCOSSJewish Free SchoolKingsburyKingsgate PrimaryLivingstoneLondon AcademyLoreeto College St AlbansLyonsdownManorsideMartinMathilda Marks KennedyMenorah Primary NW11Mill Hill CountyMillbrook ParkMonken Hadley CE PrimaryMoss HallNEETNorth London InternationalNorthgateNorthsideNot in schoolOak LodgeOakhillOrionOsidgeOur Lady of LourdesOur Lady of MuswellParkfieldPavilion Study CentreQ.E.GirlsQE BoysQueenswellRimonSacred HeartSaracensSouthgateSt AgnesSt Alban's GirlsSt Andrew's (and St Andrew the Apostle)St Andrew's CESt James' CatholicSt John's CE N11St John's CE N20St Joseph's RCSt Mary's & St John'sSt Mary's CE EN4St Monica'sSt Paul's N11St Paul's NW7St VincentStanmore CollegeSummersideSunnyfieldsThe ComptonThe HydeThe MountThe Orion SchoolTotteridge AcademyTrent SchoolTudorUnderhillWatling (Watling Park)Wessex GardensWestminster CityWhitefieldWhitings HillWolfsten HillelWoodcroft PrimaryWoodridge PrimaryWren AcademyDo not knowNot listedYear Group of Young Carer #3-Please select from options-Year 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Do not knowPlease enter the school/college Young Carer #3 attends* Who the Young Carer cares for-Please select from options-MotherFatherBrotherSisterGrandparentOtherIf Other, please state* Name of Cared For Person First Last Cared For Person's Condition Cared For Person's Date of Birth DD slash MM slash YYYY Does the Young Carer(s) live with the Cared For Person?* Yes No Please enter your postcode below and click on the Lookup Postcode button Cared For Person's Address* City* Postcode* Is the Cared For Person receiving care from an Adult Carer?* Yes No Do they wish to be referred to Barnet Carers' Adult Carers Service?* Yes No If Yes, please give the name of the Adult Carer* Email Adult Carer Adult Carer's Phone No:What areas does the Young Carer provide care:* Domestic Tasks Personal Care Emotional Support Practical Support Other If Other, please give details* Please summarise how the young carer(s) are impacted by their caring role, what you hope for the young carer to gain from the service and any additional information regarding the family situationIs there an intervention in place for the family?* Yes No If Yes, please select intervention in place* Early Help Assessment (EHA) Child In Need (CIN) Child Protection (CP) Please provide details of lead professional/allocated social worker (If preferable, CP/CIN/EHA Plans can be sent securely to youngcarers@barnetcarers.org to avoid duplication.)Are there other agencies involved? If Yes, please provide names and contact details where relevant Yes No Name of Agency Contact #1* Agency/Position #1* Contact Details #1* Name of Agency Contact #2 Agency/Position #2 Contact Details #2 Is there anyone in the family who is: (select relevant) MUST BE COMPLETED OR WE ARE UNABLE TO CARRY OUT HOME VISITS* Violent, verbally aggressive or threatening Misusing drugs and/or alcohol Involved in crime Other Not applicable Please give details [Violent, verbally aggressive or threatening]*Please give details [Misusing drugs and/or alcohol]*Please give details [Involved in crime]*Please give details [Other]*Do the home conditions pose any risk? (select relevant) MUST BE COMPLETED OR WE ARE UNABLE TO CARRY OUT HOME VISITS Threatening animals Home environmental issues Other Not applicable Please give details [Threatening animals]*Please give details [Home environmental issues]*Please give details [Other]*Are there any parking restrictions near the home?* Yes No If Yes, please give details*Does anyone in the family object to this referral?* Yes No If Yes, please give details*Consent Form We require the consent form to be completed by the parent or guardian of the young carer(s) whom you are referring into our service. It can be accesses via this link.I have sent the parent or guardian the link to the Parental Consent Form and asked for it to be completed* Yes No 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.I have sent the parent or guardian the link to the Young Carers Assessment and asked for it to be completed* Yes No