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Ainsley Bailey
Garfield Meredith
Steve Brown
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About Us
Mentor Profiles
Ainsley Bailey
Garfield Meredith
Steve Brown
Services
Protective Factors
Referrals
FNB Updates
Contact
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About Us
Mentor Profiles
Ainsley Bailey
Garfield Meredith
Steve Brown
Services
Protective Factors
Referrals
FNB Updates
Contact
Menu
About Us
Mentor Profiles
Ainsley Bailey
Garfield Meredith
Steve Brown
Services
Protective Factors
Referrals
FNB Updates
Contact
Make a Referral
Mentee Name
Mentee Preferred pronouns
Mentee Date of Birth
Mentee Full Address
Mentee Ethnicity
Email
Parent/legal guardian name
Relationship to child
Please tick all the criteria that apply:
Is a child in care
Receiving SEND support at school
Is at risk of exploitation
Has an Education and Health Care Plan
Has a disability
Is on a child protection plan
Please give details of relevant key workers Eg, Social Worker / Teacher / Youth Justice Worker
Key worker name
Job Title
Organisation
Contact Number
What schooling/education do you receive:
Not in School / College
Currently in School
Currently in College
Are you receiving support from CAMHS?
No
Yes
Referrer Details:
Referrer Name
Job title
Organisation
Referrer Contact Number
Referrer Email
What is the reason for the referral?
What are the concerns about the young person? (please tick all that apply and give more details in the box above)
Harm to self
Bereavement
Caring responsibilities
Harm from others
Employability
Offending behaviour
Anxiety/worry
Personal safety
Family problems/home life
Depression/low mood
Sexual Health
Community involvement
Physical health/illness
Discrimination
Sexuality or gender issues
COVID-19
Education support
Domestic Abuse
What needs to happen to improve things for the Young Person? (please tick all that apply
Community involvement
Crisis planning
Explore hobbies/interests
Make plans for future
Learn new coping strategies
Feel safer
Learn independent living skills
Better relationships at home
Healthier lifestyle habits
Access support/services
Make friends
What goal would the young person like to work towards? Please ensure this reflects the young person’s wishes.
Please give details about risk assessment and management below - Give details of risk to self and others
I Confirm the child is aware of and in agreement with this referral
I Confirm the parent/legal guardian is aware of and in agreement with this referral if child is under 13 and is unable to consent.
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