Are the family and the referred young person aware of this referral? (Please select) Yes No
Information regarding the young carer you are referring Young Carer’s Name
Date of Birth
Gender (Please select) Male Female Non-binary Transgender Other
Gender (Other)
Ethnicity (Please select) White Mixed or Multiple ethnic groups Asian, Asian Scottish or Asian British African, Caribbean or Black Other Ethnic Background Prefer not to say
Home Address
Postcode
Social Locality (Local Health/GP centre)
Phone Number
Email Address
Information about the parent / guardian with parental responsibility Name of Parent / Guardian
Relationship of Parent / Guardian to Young Carer
Home Phone Number
Mobile
Email
Further information Is the school aware of the caring role? (Please select) Yes No Unknown
Is the young person registered on SEEMiS as a Young Carer? (Please select) Yes No Unknown
Has consent for VAS to share information with SIC/NHS been provided? (Please select) Yes No Unknown
Can VAS Carers Service contact the school to discuss this young person? (Please select) Yes No Unknown
If yes, who would be most appropriate to contact?
Is there a Child’s Plan in place? (Please select) Yes No Unknown
If yes, who is the lead on this? Name:
Job Role and Agency:
Information about the cared for person Does the cared for person live with them? (Please select) Yes No
Name of person cared for
Address
Postcode
Social Locality (Local Health/GP centre)
Gender (Please select) Male Female Non-binary Transgender Other
Gender (Other)
Ethnicity (Please select) White Mixed or Multiple ethnic groups Asian, Asian Scottish or Asian British African, Caribbean or Black Other Ethnic Background Prefer not to say
Date of Birth (if known)
What is the illness/condition/disability of the person they care for? Please choose all that apply.
Illness/condition/disability (Other)
Is their caring role impacting on them? (Please select) None Some Lots
If you indicated some or lots above, please detail how you consider their caring role has impacted on them. Please choose all that apply.
Impact (Other)
Please briefly describe the caring role, what kind of tasks does the young person do?
If known, how long has young person been caring for?
Hours of caring? (approx.)
Any other information that you believe is relevant?
Referring Agency Your Name
Job Role / Title / Relationship to Young Carer
Referring Agency (if applicable)
Phone Number
Email Address
Data Protection Here at Voluntary Action Shetland (VAS) we take your privacy seriously and will only use your personal information to administer your account and to provide the products and services you have requested from us. In order to provide carers with a better service we are now working in partnership with Shetland Care Attendant Scheme (SCAS). We will share your information with this organisation via a joint database. If you have any concerns about this please discuss this with us.
From time to time VAS / SCAS would like to contact you with details of other services we provide. If you consent to us contacting you for this purpose, please tick to say how you would like us to contact you.
I'm happy for you to contact me by:
Where appropriate we would also like to pass your details onto Shetland Islands council and / or NHS Shetland and other third sector organisations who support carers and will pass information to you regarding being a carer or services to support the person you care for, so that they can contact you with details of services that they provide. If you consent to us passing on your details for that purpose, please tick to confirm:
I agree to share my information with:
I HAVE READ THE INFORMATION ABOVE AND I CAN CONFIRM THE DETAILS ARE CORRECT.
Agree & Send
