MENTORING REFERRAL FORM Referrer Details Referrer Name First Name Last Name Referrer’s Organisation Referrer’s Phone Number Referrer’s Email Young Person Details Young Person’s Initials Age of Young Person Gender of Young Person Cultural or Spiritual Identity (if relevant) Current Living Situation Strengths and Important Context About the Young Person Support Context Current Involvement with Services (e.g. Child Protection, Youth Justice, NDIS, Mental Health Services, etc.) Reason for Referral (What outcomes are you hoping mentoring might support?) Funding Source for mentoring service (e.g. DFFH, DOJ, organisation name, etc.) Urgency of Referral / Timeframe Expectations (Is this a priority? Are there any key dates or transitions coming up?) Matching and Consent Preferred Location for Mentoring (Face-to-face location or online only?) Preferred Mentor Attributes (if any) (e.g. Lived experience, cultural match, language, etc.) Has the Young Person Agreed to this Referral? (Yes / No / Not yet discussed) Consent to Contact Other Workers or Supports (if required) (Yes / No / Will confirm later) Thank you!
