Mentoring Referral Form

Please see referral form for Mentoring Programmes below

Before submitting the Referral Form below, please remember to review the criteria thresholds and notices on the Mentoring Info Page.

YLF MENTORING REFERRAL FORM FOR PROFESSIONALS
When submitting your referral, indicate the level of need and complete all sections below (for help, please refer to the notes/description in each section).
SECTION 1 - LEVELS OF NEED - Please Note
YLF Mentoring Programmes uses Kent Support Levels Guidance as framework for assessment. Support is only offered to Level 2 (additional support) and Level 3 (intensive support). Please attend to the young person’s needs before referring. Indicate young persons level of need and check all needs that apply in the respective Level 2 and Level 3 sections:
Level of Need(Required)
- Level 2
- Level 3
Level 2 - Child or Young Person Indicators (please check all that apply)
- I occasionally truant or have absence from school
- I have had some fixed term exclusions
- I have started to go missing or been absent from school or home
- I have not developed good attachments/relationships
- I am a young career with some responsibilities at home
- I am a teenage parent and I require some low level support
- I am not reaching my developmental milestones
- I have language/communication difficulties
- I need some low level support due to a diagnosed disability or sensory impairment
- I am showing early signs of associating with peers who are involved in crime or anti-social behaviour
- I am showing early signs of instigating or experiencing problematic sexual behaviour and language
- I have low level mental health or emotional issues or self-harm
- I am saying I want to run away
- I have disruptive/challenging behaviours
- I am at risk due to low level/emerging neglect
- I am home educated and there are concerns about my welfare
- I am negatively affected by difficult adult/family relationships
Level 2 - Parent/Carer Indicators (please check all that apply)
- My family is impacted by poverty affecting their access to appropriate services/affecting my development
- My family home is in a poor state of repair, impacting on my health/development, or there is serious level of overcrowding
- My family are facing eviction/statutory homelessness
- My parents/carers struggle to meet my needs, or they place their own needs above mine
- My parents/carers struggle to provide me with good supervision or behaviour management
- My parents/carers often do not take me to my appointments which impacts negatively on my health or development
- My parents/carers health including physical/mental/learning disability or substance misuse, impacts negatively on my health or development
- My parents/carers require support to understand my disability or sensory impairment, and lack strategies to manage
- My parents/carers are at risk of entering the Criminal Justice System due to low level of offending/anti-social behaviours
- My parents/carers used to be a Child in Care
Level 2 - Risk to me outside of home (please check all that apply)
- I am being encouraged to use substances
- I am being encouraged to truant from school
- I am being encouraged to commit low level crimes or become involved in anti-social behaviour
- I may be at risk due to content, conduct or contact online
Level 3 - Child or Young Person Indicators (please check all that apply)
- I have persistent unauthorised absence from school/NEET
- I am not on any school roll/I am Child Missing from Education (EMC)
- I am at risk of, or I have been permanently excluded from school
- I am home educated, there are significant concerns for my welfare
- There is serious delay in me achieving my developmental milestones creating significant concerns
- I regularly go missing from home or school with no explanation
- I am at risk of suicide and my family need help to support me
- I am at risk of committing crimes and need preventative support
- I am a pregnant teenager with serious concerns about me/my unborn baby
- I am vulnerable to being sexually abused or exploited
- I am vulnerable to/exhibiting intimate partner abuse/violence
- I am vulnerable due to my drugs and/or alcohol use
- I have significant disabilities and require professional support
- I am a homeless child in need, including 16-17 years old
- I am a young carer whose caring duties are affecting my outcomes
- I have significant dental decay that has not been treated
- I am a child subject of a Court Ordered Report under s7 or s37 being completed by children’s social care
- I am a child under an Education Supervision Order/Section 36 Children Act
Level 3 - Parent/Carer Indicators (please check all that apply)
- I am unborn, the level of concern requires a pre-birth risk assessment
- I am being chronically neglected. Food, warmth, and other basics are often not available. I live in very poor home conditions
- I am at risk due to the levels of domestic abuse in my family home
- I am at risk due to my parents/carers inability to parent consistently, and this is impacting negatively on my development
- I am at risk due to inappropriate childcare arrangements
- I am at risk due to my parents/carers health or disability, learning disability, or substance misuse, or their offending behaviour having a direct negative impact on me
- I am at risk due to my parents/carers own emotional or mental health difficulties, impacting on my health or development
- My family needs support to meet my disability needs
- I am Privately Fostered
- My family are being evicted despite professional/agency support
- I am at serious risk because my family mat breakdown and I will be homeless, or I may have to be looked after outside my family network
Level 3 - Risks to me outside of home (please check all that apply)
- I am being encouraged to become involved in a gang
- I am being encouraged to carry drugs/weapons
- I am at risk due to having contact with people who pose a risk of physical or sexual harm to children
- I am in a peer group that regularly go missing
- I am at risk due to improper content, contact or conduct online
- I am vulnerable to criminal/sexual exploitation or radicalisation
SECTION 2 - REFERRAL DETAILS
PLEASE COMPLETE ALL FIELDS IN DETAIL FOR REFERRAL TO BE CONSIDERED. ALL FIELDS ARE MANDATORY.
Young Person's Details
Full Name(Required)
Date of Birth(Required)
MM slash DD slash YYYY
Sex assigned at birth(Required)
Ethnic Origin(Required)
Parent/Carer Name(Required)
Address(Required)
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email(Required)
Contact Number(Required)
Young People in Care Only
If yes, how long for and reason why?
Referrer Details
Full Name(Required)
Referral Agency(Required)
Email(Required)
Contact Number(Required)
Further Information
Has the referral been discussed with the young person? If no, reasons why? Have you explained in detail that the programme will include a weekly visit from 3-6 months with certain goals to be achieved? (Programme to be tailored to the individual)(Required)
Referring for (please select):(Required)
*Please note that this is just a suggestion. The final decision belongs to the Mentoring team, after assessment
- Community Mentor
- School Mentor
- Community Nurture Group
Young person's timetable details (please select):
- Part Time
- Full Time
- EHCP
- NEET
Attendance %
School Name and Details(Required)
Reasons for referral, including details of concerning behaviour/risk statement(Required)
*please include as much detail as possible. Not enough information will result in referral exclusion
Any history of domestic violence/abuse in the home environment? (if yes, please provide details below when referring to home/placement overview)(Required)
- Yes
- No
Is there any safety/lone working information regarding direct work with the young person?(Required)
Any other agencies involved (currently, in the past, or on the waiting list for) with the young person/family?(Required)
*Please provide names and contact details if you have them – these include school counsellors or member of the school pastoral team, as well as any health and wellbeing programmes which the young person has undertaken
Any previous or current concerns regarding the young person's safety?(Required)
Health and Welfare(Required)
*Please list ALL details, i.e., specific learning difficulties/diagnosis’/medication and description of
Home/Placement Overview(Required)
*please include full details, e.g. history of DA, home dynamic, relationships etc.
Positive attributes and behaviours as well as hobbies(Required)
*please include details of successful strategies when working with the young person

List the suggested outcomes for the young person:(Required)

Outcome 1	Outcome 2	Outcome 3	Outcome 4

Religious, cultural, and ethnic background(Required)
SECTION 3 - SIGNED CONSENT
By completing the fields below you are consenting to the processing, sharing and storage of personal information as set out in the Privacy Notice for YLF Mentoring (this Notice can be found on the Mentoring Referral webpage of the YLF website)
Tick to confirm you consent/agree with the following:(Required)
- I have read and understood the terms as set in the Privacy Notice
- I have consent from the young person's parent/carer to make this referral
- The young person named on this form is aware that I am making this referral
Referrer Name(Required)
*Please type your name as signed consent
Date(Required)
MM slash DD slash YYYY
SECTION 4 - To be completed by the Mentoring Team
Assessment notes
Mentor's name
Date of Supervisions and notes
Safeguarding

Mentoring Referral Form

YLF MENTORING REFERRAL FORM FOR PROFESSIONALS

SECTION 1 - LEVELS OF NEED - Please Note

SECTION 2 - REFERRAL DETAILS

Young Person's Details

Referrer Details

Further Information

SECTION 3 - SIGNED CONSENT

SECTION 4 - To be completed by the Mentoring Team

The Young Lives Foundation

Find us on social