NEWCIS Young Carers Flintshire Referral Form - NEWCIS

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NEWCIS Young Carers Flintshire Referral Form

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NEWCIS Young Carers Flintshire Referral Form

Please ensure form is complete as we may return it for any missing information.

Please complete one form per child / young person being referred as the caring role and what they are undertaking will differ even within the same family.

Referrers name *

First

Last

Referrers contact number *

Referrers email *

Date of referral *

Team (if applicable)

Young persons details - name *

First

Last

Address *

Post Code *

County *

Date of birth *

Health conditions or specific needs that need to be considered

English / Welsh speaker *

English
Welsh

Any religious / cultural issues to take into consideration

Contact number *

Email

Please tell us which contact method would be preferred (email/phone/text)

Name of GP surgery

Are they registered as a young carer with their GP?

Yes
No
Unknown

By referring this person, you are confirming you have consent to pass personal details to NEWCIS and for NEWCIS to hold those personal details on our secure system. Please provide a signature of consent from person referred (if consent was over the phone, please specify)

Signature of parent / guardian (if person is under 18)

Signature of referrer *

How / where did young carer hear about us? Please be specific (E.g. Picked up a leaflet at GP surgery, social worker provided contact details – which team, google)

Reason for referral - what is the intended outcome for the young carer? Please include information about their caring role, the impact that it has on them and any other details including other services involved etc. *

Parent / guardian details - name *

First

Last

Date of birth

English / Welsh speaker

English
Welsh

Health conditions

Contact number

Email

Which contact method would be preferred? (Email/phone/text)

Please include any details that are important for us to be aware of (E.g. Child protection issues/safeguarding, sensitive cultural/personal circumstances etc.)

Cared for details - what is their relationship to the young carer? *

Date of birth

Primary condition *

Secondary condition (if applicable)

Current support (social Worker, OT, CHC funding etc.) *

ACEs check list – Please be aware a specific referral can be made to Families First for work with young carers who are experiencing two or more of the following

Verbal abuse
Physical abuse
Sexual abuse
Physical neglect
Emotional neglect
Parental separation
Household mental illness
Household domestic violence
Household alcohol abuse
Household drug abuse
Incarceration of a household member

Are there any identified risks? *

Environmental risk - access to property, hazards in or around property
Risk to self - safeguarding issues, self-harm, substance misuse
Risk to others - history of verbal or physical aggression, pets at the property
No known risk

Details of identified risk - If a risk is identified, details of risk must be provided, or referral will not be taken

Phone

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