Young Carers Referral Form

Young Carers Service Criteria

Please read before continuing with this referral.

To be eligible for referral to Stirling & Clackmannanshire Young Carers Service, a young person must:

Live within the Stirling or Clackmannanshire Council areas
Be aged between 7 and 17 years old
Consent to be involved with the service
Be impacted physically, emotionally, socially, and/or academically as a result of their caring role
Have limited access to appropriate support or respite, where additional support would benefit their wellbeing

This includes young people who may not provide a high level of practical care but who are still affected by the situation, for example, experiencing worry, stress, social isolation, or difficulties with school or friendships due to the cared-for person's needs or behaviours (e.g. challenging or unpredictable behaviour).

Caring Responsibilities

The young person must also experience a level of responsibility or impact related to caring, which may include:

Daily household management including laundry, cleaning, cooking, and shopping.
Financial and practical support such as helping with money matters, paying bills, or supporting communication (e.g. Makaton).
Personal care such as comforting the person they care for, keeping them company, or accompanying them when they go out.
Emotional support such as comforting the person they care for, keeping them company, or accompanying them when they go out.

Service Information

Support from Stirling & Clackmannanshire Young Carers is a time-limited service. An approximate timescale will be agreed with the young person at the start of their support.

If it becomes clear that the young person’s needs go beyond their caring role, we may suggest support from another service where this is more appropriate.

Get In Touch

If you would like to speak to a member of the Young Carers Team before making a referral, please call 01786 447003 or email youngcarers@stirlingcarers.org.uk.

Please confirm:I confirm that the young person being referred meets the above referral criteria

Your Relationship to the Young Person

Please tell us your relationship to the young person being referred:

Parent or GuardianProfessional

Professional Declaration of Consent

In order to make the referral to Stirling & Clackmannanshire Young Carers Service, you must have consent to share the young person’s information with us, and we must have consent to contact them. If the carer is aged 16 or under then consent must be given by the parent/guardian.

I confirm that I have consent to make this referral from: The young person The parents/guardians (if under 16)I confirm that Stirling & Clackmannanshire Carers has consent to contact: The young person The parents/guardians (mandatory if under 16)

Parent/Guardian Declarations

I confirm that I am the parent or legal guardian of the young person being referred I confirm that the young person is aware of this referral and is happy for the referral to be made I consent to being contacted by Stirling & Clackmannanshire Carers in relation to this referral

Young Carer's Details

First Name* Surname* Gender* Date of Birth (dd/mm/yyyy)* Address* Postcode* Phone Number* Email Address Name of School/College*

Does the young person being referred have any medical conditions (either confirmed or awaiting diagnosis; including disability, mental health condition, ASD or ADHD)?* NoYes

Please give brief details of their condition*:

Young Carer's Parent/Guardian Details

Please provide parent/guardian contact details. At least one contact number must be provided for us to be able to progress the referral.

This page contains information only required from professional referrals. Please click 'Next' to continue.

Role as a Carer

Cared for’s relationship to young person* Nature of cared for’s condition* Does the young person have a high level of responsibility for any of the following tasks?* Household ManagementPersonal CareFinancial and Practical ManagementEmotional CareNone of the aboveDetails of caring responsibilities* Is the young person the main carer?* NoYesIs the address of the cared for the same as the young person?* NoYes

If the cared for is an adult, are there other adults in the house with the young person?* NoYes

Please give details of other adults:

Are there siblings (if cared for is a sibling, are there other siblings)? NoYes

Please give details of siblings:

Are there professionals involved to support the cared for with their condition? (e.g. Mental Health Team, ReACH) NoYes

Please give details of professionals involved:

Support Requested

How does the caring role affect your child? Why you would like support from the Young Carers Service?: What kind of support do you think they will benefit from? Coping strategies to support them with their caring roleRegular breaks from their caring roleIncreasing their support networkSupport from our Young Carers newsletterOther

Please describe what other support you wish for them to receive*:

How does your child feel about getting support from the Young Carers Service? Anything else you would like us to know?

Referral Details

How does the young person’s caring role have an impact on them? (For example, emotionally, behavioural issues, academically etc.)* What are the reasons you wish to refer this young person to the Young Carers Service?* What are the main objectives that you would like the young carer to achieve?* What type of support do you think they will need from the YC Service? Coping strategies to support them with their caring roleRegular breaks from their caring roleIncreasing their support networkSupport from our Young Carers newsletterOther

Please describe what other support you wish for them to receive*:

Please note any other information which may be useful for us to know about the young person and their views on being supported by the Young Carers Service.

Referral Details cont.

Please indicate if you are aware that the young person has involvement with (tick all relevant): Educational PsychologistSocial workerCAMHSSchool nurseSEBNOther professional/agencyNot knownNone

Please list any other professionals/agencies:

Do we have consent to contact any other agency involved with the family? NoYesDo we have consent to contact the school, if appropriate? NoYesAre you happy to attend a joint home visit if the referral is taken forward? NoYesNotes

This page contains information only required from professional referrals. Please click 'Next' to continue.

Your Details

Your Name* Phone Number* Alternative Phone Number Email Address*

Your Details

Your name* Position* Organisation* Phone No.* Email*

Legal information

All information provided will be stored on our secure database and kept in accordance with data protection legislation. We will never share information with third parties without the consent of the carer or unless we are required to do so by law.