Spark2Life Referral Form Buckinghamshire (Community Mentoring)

Criteria for referral

YP is from an ethnically diverse background.
YP is in year 6 who is transitioning into year 7.
YP has low self-esteem, lack of motivation and ambition.
YP who needs help with personal identity towards recognising their full potential and self-worth.
YP having difficulty with organisation skills.
YP who wants help developing their cognitive thinking skills.

Unsuitable

Neither students and/or Parent/Guardian have given consent or shown a desire for mentoring
Students that professionals know NEED more support than 1 hour a week from a volunteer mentor & any specialist CAMHS intervention.
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: eva@spark2life.co.uk or Alison: alison@spark2life.co.uk or contact our head office on 0204 531 6208 and ask for Alison.

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* 1. Referral Type

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* 2. Name of Organisation/School

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* 3. Name of referrer

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* 4. Role of referrer

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* 5. Date of referral

Date / Time

Date

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* 6. Phone number

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* 7. Email address

Referee details:

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* 8.
First name of referee

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* 9. Surname of referee

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* 10. Date of birth

Date / Time

Date

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* 11. Gender

Male

Female

Prefer not to say

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* 12. First language

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* 13. Ethnicity

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* 14. Religion

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* 15. Reason for referral

Referee is presenting in an unacceptable manner whilst in school which could lead to an exclusion.

Referee is very quiet or shy.

Easily influenced into unacceptable behaviour by others.

Referee could do with working on their goals and developing themselves.

Intergenerational behaviours / identifying behaviours linked to parenting approaches.

Presents with mental health needs (please describe in additional comments)

Has undiagnosed SEN along with unacceptable behaviours.

Anti-social behaviour in the community

Non-violent offences

Transition from Year 6 - 7 Support

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* 16. Additional comments

17 & under referees only

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* 17. Name of School

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* 18. Year group

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* 19. Name of HOY

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* 20. Name of School DSL

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* 21. School DSL Contact

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* 22. School start date

Date

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* 23. Referee's details

Address

Address 2

City/Town

ZIP/Postal Code

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. Last known offending history

Offence

Order/sentence

Conditions

Start date

End date

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* 29. 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. Name of Organisation/School

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* 3. Name of referrer

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* 4. Role of referrer

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* 5. Date of referral

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* 6. Phone number

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* 7. Email address

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* 8. First name of referee

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* 9. Surname of referee

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* 10. Date of birth

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* 11. Gender

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* 12. First language

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* 13. Ethnicity

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* 14. Religion

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* 15. Reason for referral

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* 16. Additional comments

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* 17. Name of School

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* 18. Year group

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* 19. Name of HOY

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* 20. Name of School DSL

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* 21. School DSL Contact

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* 22. School start date

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* 23. Referee'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. Last known offending history

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* 29. Referrer's Commitment

* 8.
First name of referee