Mentoring Service Referral Form to be completed by a Professional wishing to refer a Young Carer Mentoring Service "*" indicates required fields The Barnet Young Carers Mentoring Programme gives our registered young carers an opportunity to access 8 sessions of 1:1 mentoring with an assigned member of our team. The sessions are tailored to individual needs and interests and take place in person, within the school. Restricted access to online sessions will only be available if these are not possible within the school venue, and will be considered on a case to case basis. Please note that as a service we are not clinically trained to provide emotional support for cases that may be considered above our threshold. Therefore we request for all referrers to be mindful of our referral criteria (stated below). Referral Criteria People referred to the programme must be aged between 10-24 Children must be registered with us a Young Carer to be considered to receive mentoring. Please use this link to be taken to the Professional Referral Form Parents/Guardians and Young Carers must be aware and give consent for referral. Young Carers must have a willingness to engage in this support. 1:1 mentoring will only be provided to Young Carers who are currently not receiving 1:1, such as targeted youth work, CAMHS or other counselling/therapeutic services. If the Young Carer displays severe emotional needs that are above the threshold of what the mentoring service can provide, we will not be able to provide mentoring support, however will advise or refer to appropriate services. Referral forms must be completed in as much detail as possible - leaving sections blank may delay the referral process. Acceptance of this referral will be subject to the quality of the referral form and the Young Carers team’s evaluation of Young Carers needs and urgency in relation to this service. Please complete the questions below Name of Professional* Job Title of Professional* Organisation of Professional* Contact No. of Professional*Email of Professional* Please enter your postcode below and click on the Lookup Postcode button Address of Professional City Postcode In what capacity do you know the young person?* How long have/will you be working with the young person?* Name of Young Carer* Gender of Young Carer*-Please select from options-MaleFemaleTransgenderNon-binaryYoung Carer's Date of Birth* DD slash MM slash YYYY Please enter the school's postcode below and click on the Lookup Postcode button Address of School City Postcode Name of School Contact* e.g. Head Teacher/Head of Pastoral StaffContact No. of School Contact*Email of School Contact* Is the young carer due to transition from primary to secondary, please give anticipated date of change and name of new school* Yes No Name of New School Anticipated Start Date DD slash MM slash YYYY Referral Risk Factors* N/A Aggressive, antisocial or offending behaviour Poor engagement at school Conflict in the family home Self Harm Suicidal Thoughts Other Please Check Appropriate BoxesOther, please give details*Any Risk to Mentor?* Yes No Yes, please give details*Does the young person have any SEN or additional needs that we should be aware of? I.e. Autism, Learning Disability, ADHD etc.* Yes No Yes, please give details*Are there any other agencies working with the young carer at present or in the past?* Yes No We ask to ensure there is no duplication of services.CAMHS* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalSpeech and Language Therapy* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalCounselling* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalEducational Psychology* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalBarnet Integrated Clinical Service (BICs)* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalTargeted Youth Support* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalMentoring from this agency or another agency* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalSchool Support e.g. school counselling, mentor* N/A In the Past Current Being Referred Name of Professional Contact No. of ProfessionalOther (Please mention any other agency(s) if not mentioned above)* N/A In the Past Current Being Referred Name of Agency Name of Professional Contact No. of ProfessionalReasons for Referral*Please include why the Young Carer has been referred to the service and what you and the Young Carer are hoping to achieve as a result of the service. Is there a particular role for the mentor to undertake? Please include as much detail as possible.What are you hoping to achieve for the young person following this referral?* Reducing isolation (encouraging integration into activities, social groups) Managing emotional wellbeing Tips and strategies for how to manage caring role/home life Guidance with school/future prospects Other Other, please give details*Does the Parent or Guardian Consent to this Referral?* Yes No Please refer back to Referral Criteria, relating to Parental Awareness & ConsentIs the Young Carer aware of this referral and willing to engage in the mentoring support programme?* Yes No Please refer back to Referral Criteria, relating to Young Carers must have a willingness to engage in this supportPhoneThis field is for validation purposes and should be left unchanged.
