REFERRAL FORM FOR PROMISE MENTOR AND/OR INDEPENDENT VISITOR

PLEASE EMAIL BACK TO US AT:

Type of request

Request for Mentor Request for Independent Visitor Request for Mentor and Independent Visitor

Young Person’s Information

Forename: / Current Address
Surname:
Middle name: / Town
Date of Birth: / Age / Post Code
Gender: / Male / Female / Telephone Number

Status of Carer

Ethnic Origins, Status, Disabilities, Religion

Religion: / C of E / Catholic / Methodist / Baptist / Other please state
Ethnic Origins: / White European / Afro Caribbean / African
Black European / Asian / Other please state:
Status: / Looked After / Care Order / Young carer / Care Leaver / Other please state
Disabilities: / Yes / If yes state type of disability / CP Plan

To your knowledge are there any risks associated with this young person?

YesNoIf yes, please provide details on a separate sheet.

Has a risk assessment been carried out on the young person?

YesNoIf yes, please provide details on a separate sheet.

Referring Agency

Referring Agency / CSC / Address / Contact Person

YOT

Team 4
Young carers
Education / Town / 
Health / Fax
Other / Post Code / E-mail

Birth Parents

Birth Parents
Mother (Name) / Primary Carer? / Father (Name) / Primary Carer
Address / Address
Town / Town
Post Code / Post Code
 / 

Step Parents/Partner (if applicable)

Step Parents/Partner
Step Mother (Name) / Primary Carer? / Step Father (Name) / Primary Carer
Date of Birth / dd/mm/yy / Date of Birth / dd/mm/yy
Address / Address
Town / Town
Post Code / Post Code
 / 

Foster Parents (if applicable)

Foster Parents
Foster Mother (Name) / Primary Carer? / Foster Father (Name) / Primary Carer
Address / Address
Town / Town
Post Code / Post Code
 / 

Residential Care (if applicable)

Residential Care
Head of Home / Keyworker
Address
Date of Placement
Town
Post Code
Tel / Total Previous Placements

Birth Siblings

Birth Siblings
Name / Name
Date of Birth / dd/mm/yy / Date of Birth / dd/mm/yy
Brother / Sister / Half-Brother / Half-Sister / Brother / Sister / Half-Brother / Half-Sister
Address / Address
Town / Town
Post Code / Post Code
Tel / Tel

Birth Siblings continued

Birth Siblings
Name / Name
Date of Birth / dd/mm/yy / Date of Birth / dd/mm/yy
Brother / Sister / Half-Brother / Half-Sister / Brother / Sister / Half-Brother / Half-Sister
Address / Address
Town / Town
Post Code / Post Code
Tel / Tel

Other Contacts i.e. Friends (if applicable)

Other Contacts
Name / Name
Relationship / Relationship
Address / Address
Town / Town
Post Code / Post Code
Tel / Tel

Criteria for referral

Please give details

Education

Current School/Alternative Provision
If NO current school give alternative provision
Name of Current School / Alternative Provision:
Contact Person / Contact Person
Address / Address
Town / Town
Post Code / Post Code
 / 

Employment/Further Education

Employment/Further Education
Employment / Further Education
Type of Work / College
Contact Person / Contact Person
Address / Address
Town / Town
Post Code / Post Code
 / 
Details
Is Young Person Statemented?
Has Young Person been assessed by Ed. Psych?
Has Education provision been identified?
Does Young Person have an Educational Plan?

Mentors Role

What do you see as the specific role for the Mentor to focus on?
Needs of Young Person
Does Young Person have any medical needs?
Does Young Person have any dietary needs?
Is there any contact that Young Person should not have?
Does the Young Person agree to have a Mentor?
Are the parents/carers aware of this referral?
Does Young Person have any special interest/hobby?
Further information to support this referral

Signed Print NameDate:

Please Note: We will always respond within one month if the referral is for an Independent Visitor. If the referral is for a mentor and we do not respond within one month the referral will be placed on the pending file and we will contact you if we have a suitable mentor. Please email to the PROMISE office at or alternatively post to: PROMISE, SCC, P O Box 5176, Shepton mallet, Somerset BA4 9DD Tel: 01749 822801