Self Referring Young Person

When accessing support from the Our Place Mentoring Scheme you are required to agree that the nature and content of the sessions will remain confidential between the mentor and yourself unless it is considered there are safeguarding concerns; in which case the specific concerns will be shared with a Designated Safeguarding Person or other agencies as appropriate.

To ensure any support offered by the Our Place Mentoring Scheme will be suitable and not duplicated in any way, should you currently be receiving support from other agencies we encourage you to contact us before making a referral request.

Our Place Support is registered with the Information Commissioners Office. All personal data held by Our Place Support CIC is held and processed in line with General Data Protection Regulation Legislation. Further information can be found in our Privacy Policy

Our Place Mentoring Scheme will never share personal data with any other organisation unless you provide written consent; the exception to this being if as an individual you are at risk of harm or of harming others. In this case only, relevant agencies will be informed, with appropriate information being provided.

Note: (*) marked filelds are mandatory.

Your Details

Alternative Contact details

Referral Information

How many other people live in the household?

To allow an appropriate level of support to be identified and to match a suitably skilled mentor to requirements please complete the following questions with as much information as is possible. Remember to include any historical information you feel appropriate and any current or upcoming events that are relevant.

Please contact Mentoring Team on 0121 354 40 80 or e-mail if you have any questions or would like further
information about Our Place Mentoring Scheme.

You are over 18. Please use the Self Referring Adult Form.
This form is to be used to refer children or young people under 18, please check Date of Birth. Adults can make a self-referral using the Adult Self-Referral Form.
This Person appears to be over 18. Please use the Adult Form
You are not an adult. Please use the Self Referring Young Person form
This form is for Parents/Carers over 16 years of age, check D.O.B or use alternative form
Referee is under 18 please use Child/Young Person Referral Form
Referrals can only be made for children aged 6 and above