AP AND OUTREACH REFERRAL FORM

Name of Young Person

Their Date of Birth

Date of Referral

Gender

Ethnic Origin

Cultural Group

Legal Status

Address (If applicable)

Phone

Email

School and lead contact

Lead Contact's Number

Lead Contact's Email

Social Worker's Name

Social Worker's Email

Social Worker's Phone Number

Social Worker's Mobile Number

Referrer's Name

Referrer's Email

Referrer's Phone Number

Referrer's Mobile Number

Reasons for Referral to Service Please include why the young person has been referred to the service and what you and the young person are hoping to achieve as a result of the service. Is there a particular role for the mentor to undertake? (Examples may include building resilience, managing emotions, building on confidence and self-belief, healthy relationships/signs of abuse)

Has the referral been discussed with the young person? YesNo

What are the young person’s views about the decision to refer to the AP and to appoint a mentor?

Information about the young person’s needs relevant to the identification of a mentor

Any further information about the young person’s needs relevant to the allocation of a mentor

Are there any health issues or allergies we need to be aware of

Best strategies to manage any difficult behaviour

Potential risks to worker

How many sessions (Morning or afternoon) a week would this young person be completing?

Name of person completing the form

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