Professional and parent/guardian referral form for young carers

Referral form for professionals and parent/guardians to refer young carers to Richmond Carers Centre

Referrer's details - Step 1 of 5

Notice

If you have any questions or would like to speak to a Young Carers Support Worker before completing this form, please contact the team on 020 8867 2383 or email youngcarers@richmondcarers.org

GDPR Agreement *

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Referrers details

Who is making this referral? *

I am a professional
I am a parent or guardian
I am a Young Carer aged 16+
I am a friend or family member

Referring organisation *

Please provide the name of your referring organisation *

Please provide the name of your school *

Team/department *

Your name *

First

Last

Job title *

What is your relationship with the young carer? *

Phone *

Email *

Has the young carer’s parent/guardian given their consent to this referral? *

Due to GDPR, we are unable to process referrals without prior consent by the young carer’s parent/guardian

Please explain why the parent/guardian has not given their consent to this referral? *

Do you consent to this referral? *

I confirm my consent to this referral

Due to GDPR, we are unable to process referrals without prior consent by a young carer aged over 16 or by the parent or guardian

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Is your parent/guardian aware that you are making a self-referral to Richmond Carers Centre? *

Would you like to leave a comment?

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Young carer's details

Young carer's name *

First

Last

Young carer's address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Parent/guardian's phone number *

Parent/guardian's email *

What is the best way to make contact with the parent/guardian? *

Is there anything we should be aware of when making contact? *

Date of Birth

Young carers date of birth *

Gender *

Disability or additional needs

Does the young carer have a disability or any additional needs of their own? *

Yes
No
Unsure

Please state the disability or additional needs *

EHCP

Does the young carer have an Education and Health Care Plan (EHCP)? *

Yes
No
Unsure

Please provide details of the EHCP *

Early Help Assessment

Is the young carer subject to an Early Help Assessment? *

Yes
No
Unsure

Please provide details of the Early Help Assessment *

Child in Need Plan

Is the young carer subject to a Child in Need Plan? *

Yes
No
Unsure

Please provide details of the Child in Need Plan *

Child Protection Plan

Is the young carer subject to a Child Protection Plan? *

Yes
No
Unsure

Please provide details of the Child Protection Plan *

Would you like to add details of a second young carer?

Second young carer's name *

First

Last

Second young carer's address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Second Date of Birth

Second young carer's date of birth *

Second young carer's gender *

Second Disability or additional needs

Does the second young carer have a disability or any additional needs of their own? *

Yes
No
Unsure

Please state the disability or additional needs *

Second EHCP

Does the second young carer have an Education and Health Care Plan (EHCP)? *

Yes
No
Unsure

Please provide details of the EHCP *

Second Early Help Assessment

Is the second young carer subject to an Early Help Assessment? *

Yes
No
Unsure

Please provide details of the Early Help Assessment *

Second Child in Need Plan

Is the second young carer subject to a Child in Need Plan? *

Yes
No
Unsure

Please provide details of the Child in Need Plan *

Second Child Protection Plan

Is the second young carer subject to a Child Protection Plan? *

Yes
No
Unsure

Please provide details of the Child Protection Plan *

Would you like to add details of a third young carer?

Third young carer's name *

First

Last

Third young carer's address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Third Date of Birth

Third young carer's date of birth *

Third young carer's gender *

Third Disability or additional needs

Does the third young carer have a disability or any additional needs of their own? *

Yes
No
Unsure

Please state the disability or additional needs *

Third EHCP

Does the third young carer have an Education and Health Care Plan (EHCP)? *

Yes
No
Unsure

Please provide details of the EHCP *

Third Early Help Assessment

Is the third young carer subject to an Early Help Assessment? *

Yes
No
Unsure

Please provide details of the Early Help Assessment *

Third Child in Need Plan

Is the third young carer subject to a Child in Need Plan? *

Yes
No
Unsure

Please provide details of the Child in Need Plan *

Third Child Protection Plan

Is the third young carer subject to a Child Protection Plan? *

Yes
No
Unsure

Please provide details of the Child Protection Plan *

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About the dependent

(person with the care need)

Dependent's name *

First

Last

Dependent's DOB

Dependent's date of birth *

Relationship to young carer *

Dependent's condition/disability *

Dependent's diagnosis

Has this been formally diagnosed? *

Is this under investigation by a medical or mental health professional? *

Dependent's living arrangements

Does the dependent live with the young carer? *

Please give the address or living arrangement *

Would you like to add details of a second dependent person?

Second dependent's name *

First

Last

Second dependent's DOB

Second dependent's date of birth *

Relationship to young carer *

Second dependent's condition/disability *

Second dependent's diagnosis

Has this been formally diagnosed? *

Is this under investigation by a medical or mental health professional? *

Second dependent's living arrangements

Does the second dependent person live with the young carer? *

Please give the address or living arrangement *

Would you like to add details of a third dependent person?

Third dependent's name *

First

Last

Third dependent's DOB

Third dependent's date of birth *

Relationship to young carer *

Third dependent's condition/disability *

Third dependent's diagnosis

Has this been formally diagnosed? *

Is this under investigation by a medical or mental health professional? *

Third dependent's living arrangements

Does the third dependent person live with the young carer? *

Please give the address or living arrangement *

Please give details of other family members/people living in the family home

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Name

Age

Relationship to young carer

Add a second person

Second person

Name

Age

Relationship to young carer

Add a third person

Third person

Name

Age

Relationship to young carer

Add a fourth person

Fourth person

Name

Age

Relationship to young carer

Add a fifth person

Fifth person

Name

Age

Relationship to young carer

Add a sixth person

Sixth person

Name

Age

Relationship to young carer

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Put us in the picture

Brief description of caring responsibitilites *

What does the caring role have an impact on or affect? *

Social Inclusion
Educational opportunities and achievement
Their emotional wellbeing
Their physical wellbeing
Family Relationships
Other

(tick all applicable)

Please provide details *

What is the purpose of this referral to Richmond Carers Centre? *

Information and advice
Emotional support
Contact with other young carers
Mentoring Programme
Holiday activity programme
After School Groups
Careers guidance and advice

(tick all applicable)

Is there anything specific that Richmond Carers Centre can support with? *

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Are there other organisations supporting the young carers? *

Please list the other organisations *

Risk Indicators

Please inform of us of any risk factors that our young carers support workers should be aware of before contacting and engaging with the family.

Physical abuse? *

Yes
No
Unsure

Sexual abuse? *

Yes
No
Unsure

Emotional abuse? *

Yes
No
Unsure

Neglect? *

Yes
No
Unsure

Online Abuse? *

Yes
No
Unsure

Mental Health? (including self-harm) *

Yes
No
Unsure

Aggression? *

Yes
No
Unsure

Please provide further details *

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If you have any questions or would like to speak to a Young Carers Support Worker before making a referral please contact the team on 020 8867 2383 or email youngcarers@richmondcarers.org

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Professional and parent/guardian referral form for young carers

Referral form for professionals and parent/guardians to refer young carers to Richmond Carers Centre

Notice

Referrers details

Young carer's details

About the dependent

Please give details of other family members/people living in the family home

Put us in the picture

Risk Indicators

Disclaimer

Contact our support team on 020 8867 2380