GreenHouse Mentoring Referral Form
Name of Referred
Individual:
Enter Forenames here:
Enter Surname here:
Forename(s)
Surname
Preferred Name
Address:
Note: Applications can
only be considered from
postcodes LU1, LU2,
LU3 and LU4
Date of Birth:
Enter Preferred Name here:
Address Line One:
Address Line Two (where applicable):
Town:
County:
Postcode:
Select DOB:
Ethnicity:
GenderGender:
Ethnicity:
Special Educational Needs: None / Action / Action+ / Statemented
Name of Parent/Guardian/Carer: Insert Parent/Guardian/Carer Name:
Telephone:
Landline No:
Mobile:
Mobile No:
NB: We prefer all referrals to come from Health, Education or Social Services professionals
Referral made
by (Full Name):
Referrer’s Full Name:
Job Title:
Insert Job Title Here:
Address:
Organization Name:
Address:
Town:
County:
Postcode:
Contact No.
Landline No:
E-mail address:
E-mail address:
Date:
Referral Date:
Mobile No:
Group Mentoring Only
YES / NO
Group Mentoring & 1 to 1 Mentoring YES / NO
I have informed the parents/ carers that GHM Services are usually
held in Stopsley and that transport cannot be provided.
Mentoring Type
Signature:
Preferences for mentoring meetings (select as appropriate):
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June 2017
School Based (meeting held at
education venue during open hours)
Non-School Based (meetings held at
the GreenHouse in Stopsley or other
non-educational venue)
Monday-Friday (between 09:00
& 15:00)
Tuesday to Thursday evenings
(between 18:00 & 20:00)
YES / NO
YES / NO
Saturday mornings (between
10:00 & 13:00)
YES / NO
Any other mutually agreeable
times
YES / NO
Please complete the following questions, enclosing continuation sheets
if necessary:
Reason(s) for referral (Describe in your own words - please include any special learning
needs or behavioural issues / requirements etc):
Insert text here:
Are any of the following concerns applicable to the referred individual
or related family members?
Anger Issues
Behavioural Issues
Substance Abuse
Domestic Violence
Mental Health
Demotivated
Learning Difficulties
Major/ Terminal Illness
Positive Role Model
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Self-Esteem Issues
Social Skills
Communication Issues
Young Parent
Young Carer
Sexual Abuse/ Exploitation
Bullying Issues
Other Disability
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
State Disability Insert text here:
Please now select the main reason for referral from the drop down list below:
Main Referral Category
Enter Main Category from list below
Expected outcome(s) of referred individual’s involvement with GreenHouse Mentoring:
Insert text here:
Are there any other organizations/agencies involved with this individual?
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YES / NO
If yes, please note agencies involved (case workers if applicable) and state reasons for
involvement:
Insert text here:
Is the referred individual:
Attending School?
YES / NO
Name of School if attending or excluded:
Attending College?
YES / NO
Name of College if YES:
In Employment?
YES / NO
Name of Employer if YES:
Classified as a Young Carer?
YES / NO
Subject of a Child Protection Plan?
YES / NO
Other: Insert text here:
Please disclose any other information relevant to the referral - such as hobbies and interests
etc. - and/or any implications that may have an impact on a GreenHouse Mentoring
relationship:
Insert text here:
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Does the referred individual have any medical conditions or issues which need to be taken
into account during GreenHouse Mentoring relationships?
YES / NO
If YES, please note them in this section:
Is there any other information that GreenHouse Mentoring should be aware of? e.g. Things
that might trigger difficult or challenging behaviour. If so, please provide details below:
Insert additional information here:
When complete and signed please return this form together with a completed consent form signed
by the parent/guardian/carer to:
GHM Manager, GreenHouse Mentoring, The GreenHouse, 16-22 St Thomas’ Road, Stopsley,
Luton Bedfordshire, LU2 7UY
Tel:
01582 528213
e-mail: [email protected]
web
www.greenhousementoring.org.uk
For GHM Office use only:
Date referral form received
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Receipt Acknowledged by:
June 2017
Referral Accepted by:
GreenHouse Mentoring
Parent/Guardian/Carer Consent Form
Young Person
Name:
Young Person’s Name:
School:
Insert Name of School:
Date of Birth:
Date of Birth:
Address:
School Year
Year:
Address 1:
Address 2:
Town:
County:
Postcode:
Contact No’s.
Landline No:
E-mail address:
E-mail address:
Mobile No:
Parent/Guardian/Carer (please delete as appropriate)
Name:
Parent/Guardian/Carer:
Relationship:
Insert Relationship:
Address:
(if different from
above)
Address 1:
Address 2:
Town:
County:
Postcode:
Contact No’s.
Landline No:
Mobile No:
Work No.
Landline No:
Mobile No:
E-mail address:
E-mail address:
GreenHouse Mentoring Parental Consent Form
May 2017
Second contact in case of emergency
Name:
Second Contact:
Relationship:
Insert Relationship:
Address:
(if different from
above)
Address 1:
Address 2:
Town:
County:
Postcode:
Contact No’s.
Landline No:
Mobile No:
Work No.
Landline No:
Mobile No:
E-mail address:
E-mail address:
I have read the information about the mentoring scheme and
understand that if I have any questions I can speak to a staff
member of GreenHouse Mentoring.
I understand that meetings are usually held at the
GreenHouse based in Stopsley, sometimes in school or at
other agreed safe locations.
We are unable to provide any transport.
I give consent to my child taking full part in GreenHouse
Mentoring activities.
Signed.....................................................................................
Date.........................................................................................
GreenHouse Mentoring Parental Consent Form
May 2017