Young Carers’ Service
Supporting children and young people in their caring role
Please complete and return to:
Family Action
217 Maryon Road,
Charlton, SE7 8DB
Email: greenwich@family-action.org.uk
Tel: 0208 853 9065
Referrer Details
Date of Referral Agency Name of Referrer Occupation
Agency Address:
Tel: Email:
Origin of Referral (Please Tick)
Adult Mental Health Adult Services Children’s Services School
Self Referral GCC Other (please specify)
Referrals should be shared with the family and made with their agreement. Is the client / family aware of the
referral? Yes No
PLEASE NOTE INCOMPLETE REFERRALS MAY BE RETURNED
Young Carer’s Details
Family Name First Name(s) Gender D.O.B. Ethnicity Disability Religion
Current Address: School / College:
Year:
Young Carer’s Contact Number:
Young Carer’s Email:
Parent / Carer Name:
Relationship:
Tel 1:
Tel 2:
Email:
Emergency Contact Name:
Relationship:
Tel:
Cared for Person’s Details
Full Name Gender D.O.B. Ethnicity Employed / In Education? Religion
Current Address if different from above: Relationship to Young Carer:
Contact Number:
Other Family Member Details (Please include details of Parent(s) / Carer(s) and siblings)
Full Name M/
F
D.O.B Ethnicit
y
Disabilit
y
Relationshi
p to child /
YP
Living
at
home?
Employed / Attending
nursery / school /
college?
Religion
Interpreter Needed?
Yes No Helpful Language
Person(s) requiring interpreter:
Are you aware of any Domestic Abuse (current or historic)?
If yes, please give details:
Are any of the children (now or have previously been) part of the following plans:
Type of Plan Child Protection Plan Child in Need (CHIN) TAC LAC
Name (s)
From To
Reason for Plan
Is anyone in the family subject to Probation, a Community Sentence or an Exclusion Order?
If yes, please give details:
Please list Professionals/Agencies involved and their contact details
Title/Agency Name Address Telephone
GP
Social Worker
Support Worker
School Contact
Lead Professional
Other:
Current Caring Role / Responsibilities (please tick)
Jobs around the house Undertaking Personal Care (washing/dressing etc)
Financial Responsibilities Keeping people safe
Food Shopping Looking after Siblings
Helping with Communication Looking after self
Other:
Cared for Person’s Difficulties (Please specify)
Illness:
Disability:
Mental Health Diagnosis:
Drug / Alcohol Dependency:
Please give details of the Reason for Referral
Please give details of your expectations of the work to be done
Please give details of any existing risks that we need to know about
Please attach any further relevant information. (inc: any Risk Assessments you have carried out)
Signature of Referred Person(s)…………………………………………….. Date………………………...
(If available)
Signature of Referrer………………………………………………………… Date………………………...
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