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Referrer Name
*
Job Title
*
Email Address
*
Phone Number
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Local Authority (if applicable)
Date of Referral
*
School / Organisation Name
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Student Name
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Student Date of Birth
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Day
Month
Year
Year Group
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Gender
*
Do they have an EHCP?
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Yes
No
Under Assessment
Primary Need (if known)
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SEMH
Behavioural
Safeguarding
Attendance
Disengagement from learning
Other
Please provide a brief overview of the student’s needs:
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Please select the areas where support is required. (Multiple selections allowed) Safeguarding & Exploitation:
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Child Sexual Exploitation (CSE)
Child Criminal Exploitation (CCE)
County Lines
Grooming and manipulation
Online exploitation
Consent and healthy boundaries
Sexting and image sharing
Recognising unsafe situations
How to seek help and report concerns
Other
Please select the areas where support is required. (Multiple selections allowed). Risk Behaviour & Harm Prevention:
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Drug and alcohol awareness
Vaping and nicotine
Substance misuse risks
Knife crime awareness
Gang involvement / peer pressure
Risk-taking behaviour
Consequences of criminal activity
Personal safety awareness
Other
Please select the areas where support is required. (Multiple selections allowed). Relationships & Sexual Health:
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Healthy relationships
Consent and respect
Managing peer pressure
Recognising abusive relationships
Sexual health awareness
Gender respect and equality
Other
Please select the areas where support is required. (Multiple selections allowed). Online Safety & Digital Life:
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Online safety
Cyberbullying
Digital footprint awareness
Social media pressure
Online grooming
Screen time and wellbeing
Other
Please select the areas where support is required. (Multiple selections allowed). Emotional Wellbeing & Mental Health:
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Self-esteem and confidence
Anxiety / stress management
Anger management
Emotional regulation
Building resilience
Identity and self-worth
Other
Please select the areas where support is required. (Multiple selections allowed). Personal Development & Life Skills:
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Goal setting and aspirations
Decision making
Problem solving
Communication skills
Leadership and teamwork
Financial awareness
Preparing for employment
Other
Please select the areas where support is required. (Multiple selections allowed). Citizenship & Community Awareness:
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Respect and tolerance
Diversity and inclusion
Community responsibility
Understanding the law
Positive role models
Active citizenship
Other
What would you like the mentoring programme to achieve?
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improved engagement in education
improved behaviour
increased confidence
reduction in risky behaviours
Other
Preferred support type:
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1:1 Targeted Mentoring (£55 per hour)
Small Group Mentoring (£40 per pupil per hour)
Structured Engagement Programme (minimum 6 weeks / 15 hours)
Preferred start date
*
Is the student currently subject to any safeguarding plans?
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Early Help
Child in Need
Child Protection Plan
Other
None Known
Any safeguarding information that the mentoring team should be aware of?
Please include any relevant background information, strategies that have already been tried, or specific considerations when working with the student.
*
I confirm that:
*
Parental consent has been obtained for the student to participate in mentoring support.
Information shared within this referral is accurate and relevant to the support requested.
Signature
*
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