ANGUS YOUNG CARERS – REFERRAL FORM
Date:
Referred by:
Agency:
Tel. No:
Address:
Email:
Name of young person:
MALE/ FEMALE (please circle)
Address:
Date of Birth:
Postcode:
Tel. No:
Who do they care for:
Date of Birth:
Address (if different from above):
Relationship to young person:
Diagnosed condition/s:
Is the young person aware of the referral
(If not, please make the young person aware)
YES/NO
If under 16, has the parent/ guardian consented to the referral
YES/NO
Can the parent/ guardian be contacted
YES/NO
Has a young carers assessment been carried out
YES/NO
Parent/ Guardian name:
Address (if different from above):
Postcode
Tel. No:
Please give details of all others living at home with the young person (if known)
(you do not need to include parent/ guardian already stated):
Name
Relationship to young person
D.O.B
Please give details of other agencies or services involved (if known):
Agency/service
Contact Name
Contact Number
Which family
member(s) receives
this service?
Has the referrer visited the home?
YES/NO
Has a risk assessment been carried out?
YES/NO
Are there any reasons why a lone visit should not be undertaken?
YES/NO
(if yes, please specify)__________________________________________
____________________________________________________________
Do the family own any pets?
YES/NO
(if yes, please specify)__________________________________________
What are the main caring responsibilities or duties that this young person undertakes?
Please give details of why you have referred this young person to the young carers
service and what you feel their main needs as a young carers are:
Where did you hear about us (please tick)?
 Leaflet
 Website
 School/ Further Education
 Word of mouth  Training/ Awareness- raising session
 Other, please specify_____________________________________
Please return to:
Angus Carers Centre
3 Fisheracre
Arbroath
DD11 1LE
Tel. No: 01241 439157, Fax: 01241 876903,
Email: enquiries@anguscarers.org.uk
FOR OFFICE USE ONLY (tick and initial)
Acknowledged

Input Database

Allocated
