Mentoring Referral Form
Volunteer Mentors- Listens to a young person on a 1:1 basis
- Doesn’t judge the young person
- Help guide young people to the right place to get help
- Offers support especially when things don’t go right
- Be someone you can be yourself with
- You will have someone to talk to
- Help you make sense of things that are happening in your life.
- Your mentor can listen, encourage, support and guide you and help you work towards the things you would like to be different in your life.
- Help you to follow up interests that you have or that you would like to try.
Where and When?
- During the day, evening or week-ends – whatever arrangement is good for you and the volunteer mentor
- You would usually see your mentor once a week for up to a year.
- If you decide it’s not for you it’s your choice you can stop at any time.
Referrer’s Details / Date of Referral:
Referrer Name: / Role of referrer:
How long have you known the young person and in what capacity?
Contact details of Referrer including telephone number and E mail address:
Please tell us about qualities which you value in the young person?
Please describe the young person’s strengths?
Referrer:Please give details of any other agencies offering support or who have offered support in the past:
Agency / Name of worker / Role of Agency / Contact Number / E mail
Please give details of any plans which are in place which are focused on helping the young person to be safe and enable them to reach their potential?
Type of Plan / Date of Plan / Focus of Plan / Plan Holder / If not above Contact details of Plan holder.
Young Person’s Details
Young Person’s Name: / Date of Birth:
Gender: / Ethnic Origin:
Young Person’s Address:
Parent/Carer’s Name (add address if different from young person)
Parent/Carer’s Name Contact Details (Mobile):
School Details / Current School Year:
Name of Primary School: / Dates:
Name of Secondary School: / Dates:
Any additional needs within school?
If not the referrer, the person in school that the young person has the best relationship with
Signature of Young Person: ~ Date:
Signature of Referrer: ~ Date:
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Young Person - Be Heard - Have your say!Some Young People……. / Not like me / A bit like me / A lot like me / Just like me
Have things to do in the time that they are not at school?
Feel good aboutthemselves?
Know where to go when they have a problem?
Worry about something that might happen in the future?
Would like to talk through things with an adult who would listen to how they are feeling?
Would like to try new things?
Believe that they are good at things?
Have lots of friends?
Have things is their life they would like to be different
Have ideas about how they would like their future to be
Views of Young Person and Referrer- On a scale of 1-10 please rate the areas below in terms of things that you and or others worry about? (10 being an area of worry or/difficulty)
Young Person / Referrer / Others / My worries are: / Others worry about:
Feelings and behaviour
Ways I deal with problems
My safety
School life
Family
Activities
Friendships
Health
Future
Any areas not mentioned above:
Young Person In order to help us find a mentor who you would like and get on with please tell us a bit more about yourself and how you think a mentor could help?
I like:
With 1 being the thing that you would find most helpful about having a mentor please number the following..
To have fun with _____ To talk with ______To help me with things I find hard ______To try new things ______
Please describe what you would a mentor to be like: / I would like a mentor to be:
Is there anything specific that you would like a mentor to help you with?
Referrer’s wishes for the young person:
Thank you for helping us to understand how we might be able to help you – we will be in touch with you within the next 2 weeks to let you know how we may be able to help you.
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