The young person First name of child (required) Last name of child (required) Child's Date of Birth (required) Child's Gender (required) Child's Ethnicity (required) Name of School/College (required) Child's Disability or Special Educational Needs (if any, please specify)
Please ask the young person the following:
(Please complete this with the young person, it is important it reflects their experiences.)
You must answer the 8 multiple choice questions. The follow-up questions are optional but very helpful if relevant.
1 Do you carry out personal care, manual handling or administer medication? Select DAILY OFTEN SOMETIMES RARELY NEVER 1b If relevant, please detail which personal care or medication-related tasks you carry out: 2 Do you get worried/angry/stressed as a result of your caring role? Select DAILY OFTEN SOMETIMES RARELY NEVER 2b Please detail anything in particular that worries you in relation to your caring role: 3 Is your school life impacted by your caring role? Select DAILY OFTEN SOMETIMES RARELY NEVER 3b Please detail how school life is impacted by caring role e.g. lateness/absence/bullying/feeling isolated: 4 Is your social life impacted by your caring role? 4b Please detail how social life is impacted by caring role e.g. having to come straight home from school: 5 Do you know what to do and who to contact in an emergency? (Answer 1-5, 5 being very confident). Select 5 (Very Confident) 4 3 2 1 (Very Unsure) 5b If relevant, please give an example of an emergency relating to the caring role which you have faced: 6 Do you feel well supported by the professionals in your life? Select DAILY OFTEN SOMETIMES RARELY NEVER 6b Please list existing support networks you access e.g. school counsellor/youth club: 7 Do you feel able to make independent choices in your life? Select DAILY OFTEN SOMETIMES RARELY NEVER 7b Please detail things you feel in control of e.g. courses at school, choosing games to play at home: 8 Do you feel appreciated and proud when helping the person you care for? Select DAILY OFTEN SOMETIMES RARELY NEVER 8b Please detail how your parents/adults show that they are grateful for the support provided:
Add another young person
The professional First name of professional referring (required) Last name of professional referring (required) Agency Telephone (required) E-Mail (required) Address (required) Who in the family are you working with? (required) How long do you plan to continue working with the family for (required) Family have been shown the Fair Processing Notice (opens in new window) & consent to The Carers’ Centre and Local Authority storing their details? Yes No The responsible adult Family address incl. Postcode (required) First name of Adult living with children (required) Last name of Adult living with children (required) Adult's Date of Birth (required) Adult's Gender (required) Adult's Ethnicity (required) Adult's Telephone Number (required) Adult's E-Mail (important – used to send news of upcoming events)
Add another responsible adult
The cared for person First name of cared-for person (required) Last name of cared-for person (required) Cared-for person's Date of Birth (required) Cared-for person's Gender (required) Lives at family address? Yes No Diagnosed Health Condition(s) Relation to Young Carer (required)
Add another cared for person
Existing support Name of Family/Friend/Partner that supports family
Lives at family address?
Yes No Type of support they give e.g. emotional/childcare/pick up from school etc Relation to Young Carer(s) About the referral Reasons for referral (required) Risk factors Safe for lone worker to visit home? Yes No If NO, why not? Support Plan? CP CiN TAF
If CP, Date of Registration:
If CP, Category:
Emotional Physical Sexual Neglect Many thanks for your referral.
Please note the following about our procedures:
If you are a Social Worker referring, a welcome pack will be sent to the family within 10 working days. If not, the case will first be screened by a Brighton & Hove City Council Young Carers Family Coach to ensure that the whole family is being supported appropriately. This process may take 6-8 weeks. Social Worker referrals and those screened by a Family Coach are then allocated a Young Carers Project keyworker. The family will be contacted shortly after the allocation. In summary, we aim to process social worker referrals within 2 weeks and all other referrals within 10 weeks. If you have any additional questions about our procedures, please contact our team on 01273 746 222.