Mentoring Form For Mentees / Parents / Carers

Please take your time to complete this form, as we need this information to provide you with the appropriate support. We will contact you to confirm receipt of your referral and discuss waiting times.

If more immediate contact is needed, or if you feel affected after sharing this information, here are some suggestions of what to do next:

1. Contact your GP

2. NHS First Response on 0808 196 3494 If you are feeling unsafe, distressed or worried about your mental health.

3. KOOTH online mental health support – www.kooth.com

4. Papyrus (Prevention of Young Suicide) www.papyrus-uk.org/ Call: 0800 068 4141 or Text: 07860 039967

5. Shout 85258 is a free, confidential, 24/7 text messaging support service for anyone who is struggling to cope.

Personal Information:

Your name*

Date of birth*

Age*

Gender*

Home Address*

Your Contact Number*

Email Address*

School/College

Preferred method of contact (Phone, Email, etc.):*

Supporting Information

Why do you feel you need wellbeing or mentoring support?*

Are you receiving any other support currently (e.g. from school, GP, counsellor, other services)?*
YesNo

If yes, please provide the following details
Their Name

Organisation

Contact Number

Is there anything else you'd like to share about your situation or concerns?

Parent/Guardian Consent (for under 16s)

Can we contact your Parent/Guardian?
—Please choose an option—YesNo

Parent/Guardian Name

Contact Number