School or Professional

As a referring organisation; by completing this referral you are confirming you have gained the permission of the individual requiring support and of Parents/Carers where this referral is for a Child/Young Person (under the age of 18 years old).

You must inform the individual concerned and Parents/Carers, when accessing support from the Our Place Mentoring Scheme that they are required to agree that the nature and content of mentoring sessions remains confidential between the mentor and mentee unless it is considered there are safeguarding concerns; in which case the specific concerns will be shared with a Designated Safeguarding Person or other agencies as appropriate.

To ensure any support offered by the Our Place Mentoring Scheme will be suitable and not duplicated in any way, should the individual you are referring be currently receiving support from other agencies we encourage you to contact us before making a referral.

Our Place Support is registered with the Information Commissioners Office. All personal data held by Our Place Support CIC is held and processed in line with General Data Protection Regulation Legislation. Further information can be found in our Privacy Policy

Our Place Mentoring Scheme will never share personal data with any other organisation unless the Parent/Carer provide written consent; the exception to this being if an individual is at risk of harm or of harming others. In this case only, relevant agencies will be informed, with appropriate information being provided.


Note: (*) marked filelds are mandatory.

Referrer Details

I confirm the Parents/Carers of the person being referred have given permission for Our Place Support to contact them directly.

Please contact Mentoring Team on 0121 354 40 80 or e-mail if you have any questions or would like further
information about Our Place Mentoring Scheme.

You are over 18. Please use the Self Referring Adult Form.
This form is to be used to refer children or young people under 18, please check Date of Birth. Adults can make a self-referral using the Adult Self-Referral Form.
This Person appears to be over 18. Please use the Adult Form
You are not an adult. Please use the Self Referring Young Person form
This form is for Parents/Carers over 16 years of age, check D.O.B or use alternative form
Referee is under 18 please use Child/Young Person Referral Form
Referrals can only be made for children aged 6 and above