Referral Form | Ourplace

As a parent/carers referring your child for Mentoring Support you are required to have discussed this with your child prior to completing this referral.

When accessing support from the Our Place Mentoring Scheme you are required to agree that the nature and content of the sessions will remain between the mentor and child/yong person 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, all necessary information being provided.

Note: (*) marked filelds are mandatory.

Parent/Carer Details

Title:

This field is required.

Name:

This field is required.

Surname:

This field is required.

Contact Address:

This field is required.

Postcode:

This field is required.

Contact telephone number:

This field is required.

Email Address:

This field is required.

Alternative Contact details

Title:

Name:

Relationship:

Contact Number:

Email Address:

Child/Young Persons Information

Name:

This field is required.

Surname:

This field is required.

Gender:

This field is required.

Date of Birth:

This field is required.

Age (Calculated):

Attending School:

This field is required.

Current School Year:

This field is required.

Is the Child/Young Person involved with Children’s Services, Child Need Plan or Child Protection Plan:

This field is required.

Are other professional agencies involved?:

This field is required.

Do you anticipate any difficulties in accessing Mentoring Support?:

This field is required.

Has the child/young person been referred to Our Place before?:

This field is required.

Has the child/young person any additional needs/disabilities:

This field is required.

Has the child/young person any allergies:

This field is required.

How many other people live in the household?

Adults (number):

This field is required.

Children (number):

This field is required.

Reason for Referral: (Please give as much information as possible, including details of any recent events that may be discussed):

This field is required.

What are the desired outcomes from mentoring support?:

This field is required.

Are there any reasons why the child/ Young Person would not engage well with mentoring support (what if any barriers could there be?)::

This field is required.

Consent Details

I consent to Our Place Mentoring Scheme holding and processing my or my child’s/young person personal information as required by General Data Protection Regulation legislation This field is required.

I consent to Our Place Mentoring Scheme sharing with my GP or other agencies my personal information, should it be deemed that I or someone in my care (Child/Vulnerable Adult) be at risk of harm or harming another person This field is required.

I consent to Our Place Mentoring Scheme using the provided telephone, address and email information to make direct contact. This field is required.

Preferred Method of Contact:(Please tick the boxes)

Post Phone E-mail Text This field is required.

Date:

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

Parent or Carer Referring Child or Young Person

Note: (*) marked filelds are mandatory.