Crawley & HorshamPeer Mentoring Service

Mentor Application Form

The information received on this form will be treated in confidence and in accordance with the Data Protection Act 1998.

Contact Details

Name: ______

Address: ______

Postcode: ______

Is it okay to leave a message? / Preferred method(s) of contact? (√)
Landline No.: /  Yes  No
Mobile No.: /  Yes No
Email address:

When are the best times to contact you? ______

How did you hear about the Peer Mentoring Service?
Please explain why you are interested in volunteering as a mentor for people with mental health needs:
What would you like to gain from your mentoring experience?
What specific skills and attributes could you bring to the role of mentor, and how would you use your own mental health experiences to help a mentee?
Please tell us about your interests and hobbies:
Do you consider yourself to be a mental health service user?  YES  NO
If no, have you been a mental health service user in the past? YES  NO
Do you have caring responsibilities?(Children, relatives, partner, etc.) YES  NO
Do you have any experience of volunteering in any capacity?  YES  NO
If yes, please give details:
Are you currently in employment?  YES  NO
If yes, please say what type of work it is and whether it is full or part time:
If no, please say how long you have been unemployed:
Do you have the use of a car?  YES  NO
If yes, are you currently insured for business use?  YES  NO

As this voluntary role involves working with individuals with mental health needs it is therefore exempt from the Rehabilitation of Offenders Act 1974. This means that you are not entitled to withhold information about any “spent” criminal convictions.

  1. Do you have any spent or unspent criminal convictions? YES  NO
  1. If yes, please give details of the date(s), the nature of the offence(s) and the sentence(s) on a separate piece of paper. Please mark the paper with your initials and place in a separate sealed envelope marked:‘Private and strictly confidential’. This information will be kept securely in your file; it will not necessarily exclude you from being considered for this voluntary role.

Please give the names and addresses of two people you have known you for at least 6 months who we could contact for references.These should not be members of your family. Referees will not be contacted until after you have attended an interview. If you have difficulty in thinking of someone who could act as a referee, we can talk about this when we meet.

Referee 1 / Referee 2
Name: / Name:
Address: / Address:
Postcode: / Postcode:
Phone No.: / Phone No.:
Email Address: / Email Address:
In what capacity do you know this person? / In what capacity do you know this person?

The information given on this form is correct and complete as far as I know and believe.

Signature: ______Date: ______

If you have any questions please call 01403 211593

Once completed please return this form to:

Crawley & Horsham Peer Mentoring Service Coordinator

Mind in Brighton & Hove

First Floor, Park House, North Street

Horsham, West Sussex

RH12 1RN