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*

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?*

If Other, please state*

Are you wishing to refer more than one Young Carer?*

Yes

If so, please indicate how many Young Carers you would like to refer*

Name 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*

Ethnicity of Young Carer #1

Parent/Guardian Name*

First Last

Parent/Guardian's Email

Parent/Guardian's Mobile No:

Parent/Guardian's Home Phone No:

Relationship to Young Carer #1*

Does Young Carer #1 have their own contact details?*

Yes

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*

Year Group of Young Carer #1

Please 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*

Ethnicity of Young Carer #2

Relationship to Young Carer #2*

Does Young Carer #2 have their own contact details?*

Yes

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

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*

Year Group of Young Carer #2

Please 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*

Ethnicity of Young Carer #3

Relationship to Young Carer #3*

Does Young Carer #3 have their own contact details?*

Yes

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

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*

Year Group of Young Carer #3

Please enter the school/college Young Carer #3 attends*

Who the Young Carer cares for

If 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

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

Do they wish to be referred to Barnet Carers' Adult Carers Service?*

Yes

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 situation

Is there an intervention in place for the family?*

Yes

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

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

If Yes, please give details*

Does anyone in the family object to this referral?*

Yes

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

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