Details of Referrer
Details of Young Person (Beneficiary)
In Education, Training or Working?
Social Worker/Key Worker/Personal Advisor’s details
Please give reasons for making this referral, and why this young adult would benefit from a Mentor including expected outcomes. (200 words)
What support is the young adult currently receiving? e.g. counselling, youth club, social services
Please provide any additional needs that have not been captured above, or issues that might require specific support or sensitivity.
Please state any special needs or disability that you would like us to know about. (100 words)
Other Agencies involved in the duty of care for the young person (beneficiary)
Please supply us with the names the agencies, contact person, email address and telephone number