PLEASE NOTE: this form does not work on Internet Explorer 11 – we suggest using Google Chrome or Microsoft Edge.

    Referred Individual

    (Note, applications can only be considered from postcodes LU1, LU2, LU3 and LU4)

    Parent, Guardian or Carer


    Referrer's Declaration

    • 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
    • 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.

    Preferences for Mentoring

    Monday-Friday between 09:00 and 15:00Tuesday-Thursday between 18:00 and 20:00Saturday between 10:00 and 13:00Any other times
    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 Outcomes

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

    Reasons for Referral

    Anger IssuesBehavioural IssuesBullying IssuesCommunication IssuesDemotivatedDomestic ViolenceGang AssociationLearning DifficultiesMajor/Terminal IllnessMental HealthPositive Role ModelSelf-Esteem IssuesSexual Abuse/ExploitationSocial SkillsSubstance AbuseViolenceYoung CarerYoung Parent

    Other Organisations

    Is the individual:

    Hobbies and Interests

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

    Medical Conditions

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

    Triggers and Other Information

    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: