Professionals Referral Form : Isle Of Wight Family Centres

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Parent or Carer
Young Person
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Date Referred

*

A Young Carer is a child/young person (aged 18 or under), who care, or help to care, for another family member. The person receiving care may have a physical or learning disability; a visual or hearing impairment; a physical or long term mental illness; alcohol or drug dependency. The child/young person may be carrying out domestic tasks, household management, personal care, emotional care, sibling care and/or practical/financial care.

On meeting the threshold, an assessment will be carried out to take into account the needs of the child/young person and the family.

This referral information may be shared with the family.

Please ensure all sections are completed.

Section 1: Personal Details

Name of Young Person (Young Carer)

*

Gender

Male

Female

Alternative pronoun preferred

Address Line 1

*

Address Line 2

City

*

Post Code

*

Date of Birth

*

Home Telephone

Parents Mobile

*

Parents Email

*

The child gives their consent to this referral & the information provided?

Yes

No

Please advise the family that if there is a high level of caring, the Barnardos Young Carer Service/referrer may share any relevant information with Childrens Services to ensure that the families can access further support services in line with the Carers Act 2014 and the Children & Families Act 2014.

Does the parent/carer give their consent to this referral?

Yes

No

Has an Early Help Assessment been completed?

Yes

No

Don't Know

Is the child/young person subject to a Child Protection Plan/CIN?

Yes

No

Section 2: Background details

Name of Parent/Guardian(s):

*

Name of person(s) cared for:

*

Relationship to Young Carer i.e. Mother, Father:

*

Nature of illness/condition/disability:

*

Is there a caring responsibility for siblings also?

*

List the caring tasks carried out by the young person (Physical & Emotional)

*

Please indicate any other family members that live in the household and their relationship to the young carer, During the assessment, there will be an opportunity to share information about additional carers within the household.

Person 1

Name

Date of Birth

*

Relationship

Occupation/School

Does this person have any caring responsibilities within the family?

Yes

No

Person 2

Name

Date of Birth

*

Relationship

Occupation/School

Does this person have any caring responsibilities within the family?

Yes

No

Person 3

Name

Date of Birth

*

Relationship

Occupation/School

Does this person have any caring responsibilities within the family?

Yes

No

Person 4

Name

Date of Birth

*

Relationship

Occupation/School

Does this person have any caring responsibilities within the family?

Yes

No

Section 3: Education & Leisure Information

School/College/Workplace

*

Is school/college aware of the young person’s situation?

*

Name of form tutor

*

Interests/hobbies of young carer

*

Section 4: About you (the referrer)

Name of referrer

*

Organisation & position held

*

Address

*

Telephone Number

*

Email

*

Length of time interacted with the family

*

What support are you providing?

Other agencies involved and contact names

*

Please use this section for further information i.e.

What caring role is the young person is doing? Physical tasks

Time Spent Daily

Emotional Support

Time spent Daily

Would you class their caring role as significant

Yes

No

Do you feel that this child is undertaking a high level of caring

Yes

No

If yes this needs to be reported to Childrens Services in line with the Carers act 2014 and the Children and Families Act 2014 (please refer to the Tiers of Service Definition)

Impact on their health / emotional well-being as a direct result of their caring role?

Impact on their social life as a direct result of their caring role?

Any other relevant information relating to the family situation

This form will be submitted directly to Barnardo’s email system – please take screen shots of your submission for your records

Contact

Newport Family Hub
Furrlongs
Newport
PO30 2AX

Ryde Family Hub
George Street
Ryde
PO33 2JF

Sandown Family Hub
The Fairway
Sandown
PO36 9EQ

iowfamilycentres@barnardos.org.uk

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