Thank you for choosing Our Place Mentoring Scheme for support.

Please select the appropriate referral form from the options to the left.

The referral should take approximately 20 minutes to complete.

Please ensure you provide as much relevant information as possible.

Once you begin your referral form there will be no option to save the form, ensure you have available the information outlined below before you begin:

• Consent of the person you are making the referral for (if this is not a self-referral).
• Consent of the Parent/Carer should this referral be for a Child/Young Person.
• Personal details of person being referred including date of birth (This may be your own details if you are making a self-referral).
• Parent/Carer personal details if referring a Child/Young Person.
• Contact details including home address and postcode, phone numbers and email addresses.
• Details of other professionals involved, if any (Name, role and contact details).
• Number of adults/children living in the same household.
• Information of any disabilities, additional needs or allergies for the person being referred.

There are symbols throughout the form designed to help you understand the information we are requesting, and why.

Should you require any support in completing the referral form please contact the Mentoring Team via email mentoring@ourplacesupport.org or call 0121 354 40 80.