Young Carer’s Referral Form

Young Carer’s Name

Young Carer’s Date Of Birth

Young Carer’s Gender

Young Carer’s Address

Postcode

Ethnicity

Young Carer’s Home / Main Telephone

Name Of Person Cared For

Their Date of Birth

What is the relationship of the Young Carer to the person they care for? (eg: Mum, Dad, Brother, Sister...)

What is the condition/s of the person being cared for?

Please briefly describe the caring role, what kind of tasks does the young person do? How is the young person affected?

If known how long has the young person been caring for?

Hours of caring? (approx.)

Is The Young Person On North Lanarkshire Child Protection List? Is The Young Person On North Lanarkshire Child Protection List? Yes No Don't Know

Any other information that you believe is relevant?

Referring Agency Name (if applicable)

Job Role/Title/Relationship to Young Carer

Contact No

Email

Please Confirm That The Family And The Referred Young Person Are Aware Of This Referral: Please Confirm That The Family And The Referred Young Person Are Aware Of This Referral: Yes No

Is A Young Carers Statement In Place: Is A Young Carers Statement In Place: Yes No

Parent or Guardian Name

Parent or Guardian Relationship to Young Carer

Parent or Guardian Home Tel

Parent or Guardian Mobile

Parent or Guardian Email

School/College (If Applicable)

School Year

Is the school aware of the caring role? Is the school aware of the caring role? Yes No Unknown

Can Young Carers contact the school to discuss this young person? Can Young Carers contact the school to discuss this young person? Yes No

If yes, who would be most appropriate to contact:

Is there a Child’s Plan in place? Is there a Child’s Plan in place? Yes No Unknown

If yes, who is the lead on this? Name:

Role & Agency:

Person Making This Referral, Please Select From The Following Options: Person Making This Referral, Please Select From The Following Options: Self-Referral Family Referral Professional Teacher/School Staff GP/Health Care Professional

Other (Please specify)

Date of Referral