Spark2Life Referral Form Buckinghamshire (Community Mentoring)

Criteria for referral

YP is from an ethnically diverse background.
YP would benefit from trauma informed, consistent, positive mentoring.
YP is in year 6, 7 or 8.
YP seems to have low self-esteem, lack of motivation and ambition.
YP could do with some help with understanding their personal and cultural identity and recognising their full potential and self-worth.
YP who needs support with developing their organisational and cognitive thinking skills.

Unsuitable

Neither YP and/or Parent/Guardian have given consent or shown a desire for mentoring
YP with special educational needs that professionals know NEED more support.
Nb. All referrals are subject to assessment by the Spark2Life Community Mentoring Lead to see if there is a suitable Community Mentor. FAP will be updated with the number of suitable Community Mentors.

PLEASE NOTE

Please fill in the referral form with as much information as possible. If there are any issues with the form please contact Éva at eva@spark2life.co.uk or on 07977948516.

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* 1. Referral Type

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* 2. Your name

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* 3. Your role or relationship with the young person you are referring

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* 4. Date of referral

Date / Time

Date

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* 5. Your phone number

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* 6. Your email address

Young person's details:

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* 7.
First name of young person

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* 8. Surname of young person

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* 9. Date of birth

Date

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* 10. Gender

Male

Female

Prefer not to say

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* 11. Ethnicity

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* 12. Religion

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* 13. First language

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* 14. Main reason for referral

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* 15. Please select focus areas you feel the young person needs to develop.

Self control

Consequences

Relationships (with family or friends e.g.: lack of boundaries, easily influenced)

Aspirations, long term thinking

Domestic violence, or any other previous trauma YP could use support to process

Punctuality and attendance

Family relationships

Substance misuse

Conflict resolution

Transition from Year 6 - 7 Support

Physical appearance

Youth violence/gangs

Emotional intelligence

Perceptions of Women

Overall Mental Health

Self - esteem

Communication

Exclusions

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* 16. Additional comments or any other areas you think YP could do support with

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* 17. Name of School YP attends

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* 18. Year group

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* 19. Name of head of year

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* 20. Name of School DSL

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* 21. School DSL email address:

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* 22. School start date

Date

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* 23. YP's details

Home Address

Home Address 2

City/Town

Postal Code

Parent/Carer email Address

Parent/Carer phone Number

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* 24. Consent

Parental consent obtained (for under 18's only)

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* 25. Name of Parent/carer

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* 26. Parent/carer contact

Adult referees only

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* 27. Last known offending history

Offence

Order/sentence

Conditions

Start date

End date

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* 28. Referrer's Commitment

I Agree to maintain consistent contact with Spark2life mentor & Spark2life where it pertains to the work with the referee. I agree to be available to address safeguarding issues and answerer any queries or concerns that may arise.

Spark2Life Referral Form Buckinghamshire (Community Mentoring)

Question Title

* 1. Referral Type

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* 2. Your name

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* 3. Your role or relationship with the young person you are referring

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* 4. Date of referral

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* 5. Your phone number

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* 6. Your email address

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* 7. First name of young person

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* 8. Surname of young person

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* 9. Date of birth

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* 10. Gender

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* 11. Ethnicity

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* 12. Religion

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* 13. First language

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* 14. Main reason for referral

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* 15. Please select focus areas you feel the young person needs to develop.

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* 16. Additional comments or any other areas you think YP could do support with

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* 17. Name of School YP attends

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* 18. Year group

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* 19. Name of head of year

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* 20. Name of School DSL

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* 21. School DSL email address:

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* 22. School start date

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* 23. YP's details

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* 24. Consent

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* 25. Name of Parent/carer

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* 26. Parent/carer contact

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* 27. Last known offending history

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* 28. Referrer's Commitment

* 7.
First name of young person