Young Carers Referral Form

Are the family and the referred young person aware of this referral?

Information regarding the young carer you are referring

Young Carer’s Name

Date of Birth

Gender

Ethnicity

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

Further information

Is the school aware of the caring role?

Is the young person registered on SEEMiS as a Young Carer?

Has consent for VAS to share information with SIC/NHS been provided?

Can VAS Carers Service contact the school to discuss this young person?

If yes, who would be most appropriate to contact?

Is there a Child’s Plan in place?

If yes, who is the lead on this? Name:

Job Role and Agency:

Name of person cared for

What is the condition/s of the person being cared for?

Please briefly describe the caring role, what kind of tasks does the young person do? How is the young person affected?

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.
I HAVE READ AND UNDERSTOOD AND AGREE TO THE DATA SHARING NOTIFICATION.