PLEASE NOTE: this form does not work on Internet Explorer 11 – we suggest using Google Chrome or Microsoft Edge. Referred Individual 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, LU3 and LU4) 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+ Parent, Guardian or Carer Name Type ParentGuardianCarer Telephone Mobile E-mail Referrer Full Name Job Title Organisation Name Organisation Address Contact Telephone Mobile E-mail Referral Date 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 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 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 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 IssuesDemotivationDomestic 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 ---Anger IssuesBehavioural IssuesBullying IssuesCommunication IssuesDemotivationDomestic ViolenceGang AssociationLearning DifficultiesMajor/Terminal IllnessMental HealthPositive Role ModelSelf-Esteem IssuesSexual Abuse/ExploitationSocial SkillsSubstance AbuseViolenceYoung CarerYoung Parent Other Organisations 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. Is the individual: Attending school? Yes Name of school if attending or excluded Attending college? Yes Name of college In employment? Yes Name of employer Classified as a Young Carer? Yes Subject of a Child Protection Plan Yes 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:
