Spurgeons Dudley Young Carers Service
The Workspace
All Saints Road
Wolverhampton
WV2 1EL
Tel: 01902 877550
Referral form to the Dudley Young Carer Services
IMPORTANT INFORMATION - PLEASE READ
Spurgeons Dudley Young Carers services have a responsibility to work with children, young people and families in
a considered and thoughtful manner. Therefore before completing the referral, it would be appreciated if you:
1. Read the eligibility criteria for the project (If unsure please call to discuss)
2. Discuss with the parent/guardian and the young person about the reason for the referral
3. Involve the young person and family in the completion of the form
We also ask that when you complete the referral form:
1. The young person needs to answer the MACA assessment questions on page 3
This is an indication of the caring roles being completed within the household
2.
Please complete the form with as much detail as possible
Please note that families can also self referrer. In this instance, please ask for the self referral form
Following receipt of the referral – a decision will be made about suitability of referral at point of receipt
- If suitable a decision will be made within 7 days regarding priority of the case
- Referral acknowledged within 2 weeks & Young Carers notified of status of referral
Eligibility Criteria
High Level Support of complex needs.
Requiring a co-ordinated multi-agency response to needs, lead professional required linked to CAF, 1to1
support (8 weeks time limited intervention), high levels of unmet need. Excessive or harmful levels of
caring responsibility, sole carers
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Who provide a SUBSTANTIAL amount of care (practical, personal or emotional care) on a regular basis.
Who are isolated/restricted from obtaining social and recreational activities as a result of their caring role.
Targeted support and individual support.
Requires additional 1:1 support (8 weeks time limited intervention), needs are established and can be
met with identified resources
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Who provide a SIGNIFICANT amount of care (practical, personal or emotional care) on a regular basis
Preventative Support Needs met within universal activities provision.
May need information and guidance to avoid needs escalating. Ability to self-protect and be protected
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Whose LIVES ARE AFFECTED by their caring role.
Other impacts and factors will also be considered e.g. young people
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Whose development (physical/personal/social/educational) is being impaired as a result of their caring role
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Who themselves have additional support needs
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Who may shortly be bereaved
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Whose caring responsibilities are low but will increase over time
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Who are on the Child Protection register
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Whose family is going through a crisis or is under significant pressure
Spurgeons Young Carers Service Oxfordshire is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
It is important to remember that young people can often experience the impact of family members who
have an illness or disability, but who are not involved in practical or emotional care.
CONFIDENTIAL
Referral Form
ABOUT THE YOUNG PERSON:
Surname:
First Name:
Date of Birth:
Gender:
Prefers to be known as:
Age:
Male
Female
Address:
Post Code
Telephone Number
Home
Email:
Ethnicity: (tick one box)
Mobile
White:
British
Irish
*Other White
Black or Black British:
Black Caribbean
Black African
Black Other
Chinese or Other:
*other
Unknown
Asian or Asian British:
Mixed:
Indian
Mixed White/Black African
Pakistan
Mixed White/Black Caribbean
Bangladeshi
Mixed White/Asian
*Other Asian
*Other Mixed
*If selected then enter other ethnicity here
Language
First language:
Disability
Second:
Disabled Service User: Yes
No
Unknown Type of disability
School:
Tutor:
Who should we contact
to discuss the referral?
Please select
young person
What is their preferred
method of contact?
Please select
via school
parent
email
telephone
Category of need : Please select
Child protection
Child in need
Looked after
TAC/TAF
Information /sign posting required
Other please state
ABOUT THE PERSON BEING CARED FOR:
Name of person cared
for:
What is their
relationship to the young
person?
Outline of illness or
disability
Spurgeons Young Carers Service Dudley is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
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1. Outline family structure, e.g. draw immediate family tree, give names of young person’s parents and siblings
2. What sort of care does the young person provide?
Please be as comprehensive as possible
Does the YP complete the task?
Caring task
Never
(√)
Some of
the time (√)
All of the
time (√)
How do you think this affects
them?
Cleaning rooms (not just bedroom)
Washing up dishes or doing the
dishwasher
Taking responsibility for food shopping
Help with lifting the cared for
Help with financial matters i.e. paying
the bills, having a part time job to bring
the money in
Interpret, sign or use some other
communication system for the person
you care for
Help the person you care for get
dressed/undressed
Help the person you care for have a
wash/shower/bath
Keeping the person you care for
company
Keeping an eye on the person you
care for to make sure they are alright
Take the person you care for out and
about i.e. for a walk or to see friends
Take brothers and sisters to school
Look after brothers/sister (please
indicate if this is with an adult near by
or on own)
3. Has the young person ever been excluded from school
YES
NO
Spurgeons Young Carers Service Dudley is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
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4. Is the young person affected themselves by
(please select as many as are appropriate):
Drug / alcohol misuse
Self Harming
Emotional Stress
Social Isolation
NEET
Additional needs
5. Particular needs of the young person
6. What is the reason for the referral?
7. Please provide brief relevant details of family circumstances, e.g. relationship problems, transport or financial
difficulties, learning disabilities
8. Which other agencies are involved in supporting the young person and/or the family? Please state the name
and contact professionals and organisations involved
9. Has there been a separate assessment of the young person’s needs?
Yes
No
If so, please provide brief details of the type of assessment completed (Attach if consent given to share).
10. Does the family have a CAF/TAC? If so, who is the lead professional? When was it initiated? (Please enclose
copy of CAF if consent given)
11. What has been your involvement with the young person?
Spurgeons Young Carers Service Dudley is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
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12. Is there any further information we should be aware of i.e. child protection concerns or risks to lone
working?
13. Is the young person aware of the referral?
Yes
/ No
If No go to (16) Declaration
14. What does the young person want out of the project?
15. Is there anything the young person would like the project to know?
16. DECLARATION BY PARENT
I consent to the Spurgeons Dudley Young Carers Service holding personal details about myself, the young
carer and my family in accordance with the Data Protection Act 1998.
Signed
Date
17. DECLARATION BY REFERRER
Name
Signed
Position
Organisation
Address
Telephone
Date
Email
Office use only:
Worker and Date
received by DYC
Case allocated to:
Date allocated:
Action agreed:
Spurgeons Young Carers Service Dudley is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
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Service level
identified from
referral
Date
Signed
CHYMS NO.
Who we are
Spurgeons Young Carers Service Dudley works on behalf of Dudley MBC to offer a supportive service to Young
Carers under the age of 18 years living in the Dudley borough, whose lives are affected by caring for a
parent/sibling/grandparent/partner who has a disability or long term illness, including mental ill health, drug or
alcohol related illness and/or learning disabilities. Caring may be physical or emotional or both. There are various
types of support that can be offered to the young carer, including:
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1-2-1 young carer support
Information and guidance on how to access a school group or young carers youth club within the borough
Telephone support
Emotional support through counselling
Mentoring support
Training sessions and workshops
Holiday respite activities
10 week F.U.N (Fitness, understanding, Nutrition programme for young carers)
Regular newsletters to Young Carers throughout the year
Support at professional meetings, giving young carers a voice to be heard
Sign posting and referral to other agencies who can offer support
School support and transitions to college/university or employment
Spurgeons also works in schools and colleges supporting them to recognise who young carers are and
gain an understanding into the support required for young carers to reach their full potential
What to expect from a Home Visit
Before registering as a young carer, it is sometimes necessary for a support worker from Spurgeons to meet with
the young carer(s) and their family within the home or community setting, in order to carry out a full assessment of
the young carer’s needs and circumstances.
Home visits are carried out in a relaxed, friendly and informal manner. An assessment can take anything between
45 minutes to 1.5 hours and are usually with one, but sometimes two support workers present, depending on the
needs of the particular family.
Young Carer assessments centre around two A4 size forms known as the MACA and PANOC. Wherever
possible, a MACA assessment is carried out prior to the visit (by incorporating the questions into the referral form)
and provides an opportunity to understand what the young carer does e.g. helping to do housework because
Mum or Dad are unable to, or looking after a brother or sister because of a disability.
The PANOC looks at what the young carer is thinking and feeling about their caring role and wherever possible it
is encouraged that the young carer and the support worker discuss this confidentially so that an accurate
reflection of feelings can be recorded. It is the MACA and PANOC scores that largely help us to determine
whether the young person who has been referred is eligible to be registered as a young carer.
A pre CAF or full CAF form is also completed if required to ensure a whole family approach is captured and to
determine the level of service required from Dudley Young Carers. This will be shared with the family to sign and
gain consent to share or take further action to a TAC/TAF meeting where required.
If there is no illness, disability, mental ill health, Drugs or alcohol misuse identified then a care role may not be
defined. Helping out is outside our definition of being a young carer.
During the home visit assessment, the support worker will also look at the ‘whole family’ situation. This is to
ensure that there are no gaps in adult or child support. For example, if a young carer is looking after a disabled
parent, we would check to see if the parent had the necessary adult support services, as clearly this impacts on
the level of caring that the young carer is required to do. Wherever possible, we would sign post adults or
children to appropriate organisations that could provide the support we were unable to provide.
Spurgeons Young Carers Service Dudley is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
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Therefore the purpose of the home visit is twofold; it provides an initial assessment to determine eligibility and for
those who are accepted onto the project, provides a variety of opportunities of support to the young carer.
Lastly, it is important to know that everything discussed at a home visit is confidential and information can only be
shared if consent is provided. We are committed to the principle that children and families should be at the heart
of the decision making process and we hope that at the end of a home visit, you feel confident and reassured that
this is so. Unless we feel a child is at risk or harm, we will then follow our safeguarding procedures and contact
Children’s services.
Spurgeons Young Carers Service Dudley is part of Spurgeons, registered office;
74 Wellingborough Road, Rushden, Northants NN10 9TY.
Company Limited by Guarantee in England no. 3990460.
Registered charity no. 1081182.
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