Referral Form Be Free YC provides respite opportunities to young carers, to allow them to have a break from their caring responsibilities and make new friends who understand their situation. When respite alone is not enough, additional services can be available at the charity’s discretion. This includes emotional support and befriending once support workers have assessed the need. Young Carer Full Name of young carer: Date Of Birth Ethnicity —Please choose an option—Asian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - JapaneseAsian Or Asian British - PakistaniAsian British Asian - Any other Asian BackgroundBlack Or Black British - AfricanBlack or Black British - Black CaribbeanBlack or Black British - Any Other Black BackgroundGypsy/roma/travellerMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanMixed - Any Other Mixed BackgroundWhite - White BritishWhite - White IrishWhite - EuropeanWhite - Other White BackgroundOther Ethnic GroupDecline to give Not stated Parent/Guardian(s) Name: Address Gender: Pronouns: Parent/Guardian contacts Email Telephone Mobile School Young Carers with additional needs can be referred, however Be Free does not have the capacity or training to provide one to one support on trips or activities. If a young carer has difficulties following instructions, regulating emotions, or engaging with others, it may not be appropriate for them to attend trips and activities for their own safety and/or the safety of others around them. We encourage you to contact support workers prior to referring a young carer with additional needs to discuss if we are able to support them. Does the young carer have their own disability/illness or behavioural issues? If yes, how are these needs currently being met? Person Cared For Name of Cared For DOB of Cared For Relationship to young carer (eg: sibling, parent, grandparent) Please give brief details of the cared for person’s health issue (eg: illness, physical disability, learning disability, mental health, substance misuse, domestic violence) What other help is available for the cared for? Assessment of Caring Role and Impact on Young Carer Please complete this with input from the young carer and their parents. How many days a week does the young carer do the following? Undertake domestic tasks such as cleaning or laundry that exceed daily chores typical of their age 0 days1-3 days4+ days Cook or help to provide meals for their family 0 days1-3 days4+ days Interpret, sign or use any other communication system for the person they care for. 0 days1-3 days4+ days Help their cared for with personal care including washing, dressing, bathing, toileting and medication monitoring 0 days1-3 days4+ days Monitor the health and/or emotional wellbeing of the person they care for 0 days1-3 days4+ days Responsible for siblings inside and/or outside the home 0 days1-3 days4+ days How many days a week does the young carer experience the following due to their caring role: Stress and frustration 0 days1-3 days4+ days Loneliness and isolation 0 days1-3 days4+ days Unable to control emotions and/or behaviour 0 days1-3 days4+ days Uncontrollable worry for their cared-for 0 days1-3 days4+ days A negative impact on education including low attendance, difficult friendships, no access to afterschool clubs and missed homework 0 days1-3 days4+ days Low mood 0 days1-3 days4+ days Disturbed sleep 0 days1-3 days4+ days Please provide further details if necessary Is the young person/family aware that you are making this referral? YesNo Can Be Free YC make direct contact with them at home? YesNo Has the young person received a Young Carers Needs Assessment? YesNoUnsure Are professionals currently involved with the young person or family? YesNoUnsure If so, please give detail: Are there any other matters or concerns Be Free YC should be aware of when contacting/visiting the family? If so, details please: Contact details of person making this referral Name Job Title Organisation Contact Number Email
Be Free YCBe Free YC