Referral Form

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Please confirm all the following statements before proceeding with the referral *

The young person is between 8-17 years old
The young person lives in the Winchester District
The young person is caring for a family member
The young person is aware of the referral
The parent / guardian(s) consent to the referral
School/college is aware of the referral

Young Carer Details

Young Carer name *

First

Last

Age *

Date of birth *

Gender *

School/College name or Home Education *

Year group *

Why have they been identified as being a young carer? *

Does the young carer have a recognised disability/condition themselves? *

Is the young person aware of, and do they understand, the illness or disability of their cared for individual? *

How much caring responsibility does the young person have? *

What are the impacts of caring on the young person? *

What support needs have been identified for the young person, and if so, how have these been addressed at home and/or school? *

Referrer Details

Referrer name *

First

Last

Referrer role (Parent/Guardian, Social Worker, Teacher) *

Email address *

Phone number *

Address / Place of work *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Parent/Guardian Details

Parent/Guardian name *

First

Last

Parent/Guardian's email address *

Parent/Guardian's phone number *

Parent/Guardian's alternate phone number

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Parent/Guardian's D.O.B (if known)

Is the family part of the following plan?

Child protection (CP) plan
Child in need (CIN) plan
Supported families

What is the family structure? (Who lives at home?) *

2nd family member name

First

Last

Relationship to young carer

2nd family member D.O.B

3rd family member name

First

Last

Relationship to young carer

3rd family member D.O.B

4th family member name

First

Last

Relationship to young carer

4th family member D.O.B

Other family members

Cared For Details

Cared for name *

First

Last

Relationship to young carer (e.g. brother, sister, mum, dad) *

Date of birth (if known)

Please give as much detail about the illness, disability, or long-term health condition *

Type of illness *

Physical disability
Ill mental health
Drug / Alcohol dependency
Learning Disability
Long term health condition

How does this affect the family? *

Support – any agencies supporting the family

Agency 1 – contact name

First

Last

Agency 1 position/role

Email address

Agency 1 phone number

What support are they providing?

Agency 2 – contact name

First

Last

Agency 2 position

Email address

Agency 2 phone number

What support are they providing?

Agency 3 contact name

First

Last

Agency 3 position

Email address

Agency 3 phone number

What support are they providing?

Please note details of any other agencies providing support here:

Consent

Young Carer Details

Referrer Details

Parent/Guardian Details

Cared For Details

Support – any agencies supporting the family