Referral Form

Forename(s)
Surname(s)
Address Line 1
Address Line 2
Address Line 3
Address Town
Address Postcode
(Note, applications can only be considered from postcodes LU1, LU2 and LU3)
Date of Birth
Ethnicity Asian (Bangladeshi)Asian (Indian)Asian (Other)Asian (Pakistani)Black (African)Black (Caribbean)Black (Other)ChineseChinese (Other)Mixed (Other)Mixed (White & Asian)Mixed (White & Black African)Mixed (White & Black Caribbean)White (British)White (Irish)White (Other)
Gender MaleFemaleOther
Special Educational Needs NoneStatementedStatemented/EHCPActionAction+

Name
Type ParentGuardianCarer
Telephone
Mobile
E-mail
Parent/Guardian/Carer has agreed to child attending GHM? Yes
Parent/Guardian/Carer is prepared to travel to Stopsley? Yes

Full Name
Job Title
Organisation Name
Organisation Address
Contact Telephone
Mobile
E-mail
Referral Date

• I have informed the parents/ carers that GHM Services are usually held in Stopsley and that transport cannot be provided.

• I understand that GreenHouse Mentoring (GHM) will hold my information securely and use it only for the purposes of GHM work in accordance with the GHM Privacy Notice https://greenhousementoring.org.uk/wp-content/uploads/2018/04/GHM-Privacy-Notice.pdf

• I understand this information will be kept confidential, and only disclosed, without further consent, in the event that GreenHouse Mentoring is required by law to do so and that I have the right to see this information at any time.

I accept the above

Tuesday-Thursday between 18:00 and 20:00Saturday between 10:00 and 13:00
Monday-Friday daytime meetings are school-based, taking place at an education venue during open hours.
Other meetings are non-school-based, held at the GreenHouse in Stopsley or another (non-educational) venue.

Expected outcome(s) of referred individual’s involvement with GreenHouse Mentoring:

Reason(s) for referral (Describe in your own words - please include any special learning needs or behavioural issues / requirements etc):

Are any of the following concerns applicable to the referred individual?

Anger IssuesBehavioural IssuesBullying IssuesCommunication IssuesDemotivatedDomestic ViolenceGang AssociationLearning DifficultiesMajor/Terminal IllnessMental HealthPositive Role ModelSelf-Esteem IssuesSexual Abuse/ExploitationSocial SkillsSubstance AbuseViolenceYoung CarerYoung Parent
Is there another disability we should be aware of? Yes
If so, please give details
Please select the main reason for referral
—Please choose an option—Anger IssuesBehavioural IssuesBullying IssuesCommunication IssuesDemotivatedDomestic ViolenceGang AssociationLearning DifficultiesMajor/Terminal IllnessMental HealthPositive Role ModelSelf-Esteem IssuesSexual Abuse/ExploitationSocial SkillsSubstance AbuseViolenceYoung CarerYoung Parent

Are any other organisations/agencies involved with this individual? If so, please note them here (including case workers if applicable) and state reasons for their involvement.

Attending school? Yes
Name of school if attending or excluded
Classified as a Young Carer? Yes
Subject of a Child Protection Plan Yes

Are you aware of any hobbies and/or interests that it would be useful to know about during a relationship?

Does the referred individual have any medical conditions or issues which need to be taken into account during GreenHouse Mentoring relationships?

Is there any other information that GreenHouse should be aware of during mentoring - in particular, things that might trigger difficult or challenging behaviour? If so, please provide details below: