Referral Form | peermentoring

This referral form can be used for young people aged 16-25 years old who are Birmingham residents requesting Peer Mentoring support and who identify as being Black, Asian, or Minoritised Ethnicity and/or disabled and/or LGBT+.

Our Place Support is registered with the Information Commissioners Office. All personal data held by Our Place Support 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.

Details

Section 1: Referrer Details

Are you self-referring or referring on behalf of someone?:

First Name:

This field is required.

Surname:

This field is required.

Date of birth:

This field is required.

Age (Calculated):

Home address:

This field is required.

Locality:

Post Code:

This field is required.

Email Address:

This field is required.

Contact Telephone Number:

This field is required.

Emergency Contact Details

Name:

Relationship:

Email Address:

Contact Telephone Number:

Section 3: Referral Information

To allow an appropriate level of support to be identified and to match a suitably skilled Peer 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 provide as much information as possible):

What would you like to get out of Peer Mentoring?:

Are any other professional agencies involved? Include details of lead professional including name and contact details:

Days and times available to meet with mentor:

Section 4: Young Person Demographic Information

All information collected in this section is confidential and will only be accessed by the Our Place Mentoring Scheme Coordinator and Our Place Mentoring Scheme Manager to assign cases, support your needs and wellbeing throughout the project and (when anonymised) to inform project reports.

Ethnicity:

Gender identity:

Sexual Identity:

Disability Status

Note: You do not need an official medical diagnosis to receive mentoring

Consent Details

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 with my GP or other agencies my personal information, should it be deemed that I or someone in my care (Child/Vulnerable Adult) be 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:

Peer Mentoring Referral Form

Note: (*) marked filelds are mandatory.