Membership Referral Form

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Referrers: Name *

Referrers: Organisation

Referrers: Phone Number

Referrers: Email *

Young Persons: Name *

Young Persons: Date of Birth

Young Persons: Gender

Male
Female
Prefer Not To Say

Young Persons: Address

Young Persons: Phone Number

Young Persons: Email *

Young Persons: Parent's Name *

Young Persons: Parent's Phone Number

Young Persons: Parent's Email *

Reason For Referral

Please let us know why you believe this young person would engage in and benefit from mentoring: (e.g. academic support, low confidence, social wellbeing, cultural support, family/community issues, transition support)

Current Situation

Not in education, employment, or training
At risk of exclusion or school withdrawal
Involved in/at risk of crime, violence, or risk-taking behaviour
Family/community problems
Ongoing struggles with wellbeing and mental health

Does the young person have an ECHP?

risk? Persons: information

As far as you know, does the young person have any additional support needs?

(Such as neurodiverse conditions, learning difficulties or disabilities, physical disabilities, mental health challenges)

As far as you know, does the young person have any behavioural or support needs that may put themselves or others at risk?

Is the young person being supported by any other services, whether statutory, charity or other?

Parental / Carer Consent

I confirm that the parent/carer has been informed about this referral and has given consent for the young person to participate in the mentoring programme.

Additional Information

Any cultural, language, access, or safeguarding considerations we should be aware of:

Referrer signature: Please type your name here to confirm that you understand that the information you are providing in this form is being collected under the Data Protection Act 1998. It will form part of the young person’s file and if the young person requests to see information that Changing Suits (registered FYI C.I.C) hold on them, under the Data Protection Act 1998, we would release this information.

Type Name