Referral Form | Ourplace

When accessing support from the Our Place Mentoring Scheme you are required to agree that the nature and content of the sessions will remain confidential between the mentor and yourself 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 you currently be receiving support from other agencies we encourage you to contact us before making a referral request.

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 you provide written consent; the exception to this being if as an individual you are 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.

Your Details

Title:

This field is required.

Name:

This field is required.

Surname:

This field is required.

Date of Birth:

This field is required.

Age (Calculated):

Gender:

This field is required.

Home address:

This field is required.

Postcode:

This field is required.

E-Mail Address:

Contact telephone number:

This field is required.

Alternative Contact details

Title:

Name:

Relationship:

Contact Number:

Email Address:

GP Surgery Name/Contact Telephone Number:

Referral Information

Are you involved with Adult Services, a Child Protection or Child Need Plan:

This field is required.

Are other professional agencies involved, include details of lead person and contact details:

This field is required.

Do you anticipate any difficulties in accessing Mentoring Support?:

This field is required.

Have you been referred before?:

This field is required.

Have you any additional needs/disabilities:

This field is required.

Have you any allergies:

This field is required.

How many other people live in the household?

Adults (number):

Children (number):

This field is required.

To allow an appropriate level of support to be identified and to match a suitably skilled mentor to requirements please complete the following questions with as much information as is possible. Remember to include any historical information you feel appropriate and any current or upcoming events that are relevant.

Reason for Referral: (Please give as much information as possible, including details of any recent events that may be discussed):

This field is required.

What would you like to get out of your mentoring support?:

This field is required.

Are there any reasons why you would not engage well with a mentoring support programme? (What barriers, if any, could there be?):

This field is required.

Days and Time available to meet with Our Place Mentor:

This field is required.

I consent to Our Place Mentoring Scheme holding and processing my personal information as required by General Data Protection Regulation legislation This field is required.

I consent to Our Place Mentoring Scheme sharing my information with Children's Services or my GP should it be deemed I am at risk of harm or harming another person. This field is required.

I consent to Our Place Mentoring Scheme using the provided telephone, address and email information to make direct contact. This field is required.

Preferred Method of Contact:(Please tick the boxes)

Post Phone E-mail Text This field is required.

Date:

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

Self Referring Young Person

Note: (*) marked filelds are mandatory.