Valour Youth

VALOUR YOUTH

Mentoring Application Form
MIGHTY MEN OF VALOUR
Mentoring |Training | Advocacy | Employment
PO Box 1417, Croydon, Surrey, CR9 0XJ

T: 0800 073 1325; M: 07958 770 779; F: 020 8240 7485; W: http://www.mightymenofvalour.org
Office hours - Monday to Friday: 0800 073 1325 10.30am to 3.30pm

Out of office hours: 07958 770 779.

Mighty Men of Valour a Company Registered in England No.05515628
CHARITY REGISTRATION NO: 1128154
Young Persons Details

Young Person name and reason for the referral
Mentees Full Name*

PrefixFirst NameLast Name
Reason for this referral*
What are the needs that this young person have?
Date of referral:

DayMonthYear
Parent / Guardian's Main Contact Details

Young Person/ Parent/ Carer/ Guardian
Parent's Full Name (main contact) *

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Mobile Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number
E-mail*
Other Family Languages:
Parent / Guardian's Second Contact Details

Young Person/ Parent/ Carer/ Guardian
Parent's Full Name (second contact)

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postal CodeCountry
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
E-mail
example@example.com
Young Persons details/support needs:
Date of Birth:*
Age *
Gender*

MaleFemaleN/A
Class/Form/Yr:
Child/Family background information*
Please add any information which is relevant to this young person e.g. siblings, concerns, etc.
How many hours support has been allocated to during School week? (Term-Time)*
Term-time (Eveings and Weekends)
How many hours support has been allocated to during School Holidays? (Non-Term Time) *
Holidays - Monday to Sunday
Health awareness*

Do you have a disability?Do you have a learning difficulty?Do you suffer from Epilepsy?Do you take medication?Other
What is your ethnic group ?*

White BritishWhite IrishOther White backgroundBlack Caribbean and WhiteAsian and WhiteBlack African and WhiteOther Mixed backgroundIndianBangladeshiPakistaniOther Asian backgroundCaribbeanAfricanOther Black backgroundChineseOther
Pupil family background information (Please tick all that apply)*

Dual ParentsLone ParentLive with Carers/GuardiansIssues of DVChild Protection (CP)Child In Need (CIN)Other
How much Screen Time /Computer Time your child have at home/ during the day and are these sessions supervised*
How much Screen Time, including TV, Computers, Video Games, Tables, Mobile Phones etc
Child Protection Plan Y/N*

YesNo
Can we have a copy of the young person's Educational, Health and Care (ECH) plan?*

YesNoOther
Other Professionals involved in supporting young person:

Social Services, CAMHS, Speech and Language etc.
Any other Professionals involved in young person's support?*
Please add any professional who are involved in this young person's support e.g. CAHMS etc.
Who has made this referral:

Parent/ School/ Social Services/ /Head Teacher/Lead Professional
Name of person making the referral:*
Name of Person who has made the referral
E-mail*
example@example.com
Dept./Team*
Who has made this referral?*

SchoolSocial ServicesParent/FamilyOther
Phone Number*

Area CodePhone Number
Mobile Number

Area CodePhone Number
Address (if different for Above)*

Street Address

Street Address Line 2

CityCounty

Postal Code
Can we have your managers/supervisors contact details please?

School/ Social Services/ /Head Teacher/Lead Professional
Name of managers/supervisor:*
Name of managers/supervisor who has made the referral
E-mail*
example@example.com
Dept./Team*
Mobile Number*

Area CodePhone Number
Address (if different for Above)*

Street Address

Street Address Line 2

CityCounty

Postal Code
I/We consent to Mighty Men of Valour (Valour Youth) holding and using our Personal Data for the purpose of mentor/supporting this young person. Mighty Men of Valour (Valour Youth) will not pass your details to any third parties without your consent.
Do you give Valour Youth (MMOV) permission to mentor this child:*

YesNo
Do you give Valour Youth (MMOV) permission to take photographs/videos for evidence of development:*

YesNoOther
Where did you hear about our service?*

SchoolSocial ServicesParent/FamilyColleagueFriendManagerWebsiteOther
Signature of person making the Referral*
Signature of Parent/ Carer/ Guardian
Date of Signature*

MonthDayYear
Date
Type of Support required and Outcomes:

Agreed Outcomes
What changes do you want to see at the end of our support: (Please state 3 outcomes)*
Main reason for referral (please tick all that apply)*

Gifted and talentedAttendance/truancy/punctualityUnderachievementBehaviourSocial SkillsFollowing exclusionHealthEmotionalBereavementOther.....................................................................
Key Issues of concern (please tick all that apply)*

Self—esteem ConfidenceTransitionBehaviourRelationship with peersRelationship with adultsRelationship with Parent(s)Risk of exclusionAnger ManagementOrganisational skillsClass work/homeworkOther......................................................................
Does the young person require:*

Mentoring at SchoolMentoring at home (evenings)Mentoring at home (weekends)Other
Does the young person require:*

Male MentorFemale MentorNo preferenceOther
How will this support funded?
How many sessions required?*

6 sessions12 sessionsOngoingOther
Who will be funding this support?*

SchoolSocial ServicesParent/FamilyOther
Please print and check referral form before submitting it.
For office use only
Payment Details/ Purchase Orders
Cost of Support per session
Start Referral received

MonthDayYear
Date
Payment Structure
Date Mentoring/ Support Started

MonthDayYear
Date
Should be Empty:

Young Persons Details

Parent / Guardian's Main Contact Details

Parent / Guardian's Second Contact Details

Young Persons details/support needs:

Other Professionals involved in supporting young person:

Who has made this referral:

Can we have your managers/supervisors contact details please?

Type of Support required and Outcomes:

How will this support funded?

For office use only