Consultation

Mentoring Referral Form

Please be as accurate and as specific as possible when filling in this form to help allocate the most suitable service provider.

What is your relationship to the young person? *

Parent/GuardianSiblingThe referral is for me

Your Email Address *

What school year is the young person in? *

Year 6/7Year 8/9Year 10/11Year 12/13

What Borough does the young person attend school in? *

What is the young person's APS (Average Points Score) if known?

Does the young person often get in trouble in school? *

FrequentlySometimesRarely

Please provide a brief description of why you believe this young person would benefit from having a mentor. *

What specific goals or outcomes does the young person hope to achieve through mentorship?

Are any other agencies currently working with this young person?*

(e.g. Housing, Police, Youth Offending Service, Voluntary Sector, Mental Health, Educational Welfare, Learning Mentor, Benefits Agency, Social Services and Youth Organisations)

HousingPoliceYouth Offending ServiceVoluntary SectorMental HealthEducational WelfareLearning MentorBenefits AgencySocial ServicesYouth OrganisationsOther

Please highlight any other information that will help with the mentoring