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Develop Me: Mentee Referral Form

Develop Me is a mentoring programme with Birmingham Children’s Trust that supports children and young people in care.

If you feel you would like a mentor to help you overcome obstacles in your life or gain a supportive relationship from an adult who can offer you guidance and support and set goals together to work towards - please complete this form.

Read Birmingham Children's Trust Privacy Statement website: www.birminghamchildrenstrust.co.uk/privacy
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Are you a Trust staff member completing this form on behalf of a young person/young adult?

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Details of professional If referring (Name and contact details)
Date of referral *
Full name *
Address *
Email Address *
Mobile Number *
Date of Birth *
Gender *
Nationality *
Ethnicity 
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First Language *
Have you discussed your referral with a social worker?
 *
Why would you like a mentor? *

Please give information why you would like a mentor and what you would like to achieve as a result of having a mentor. Is there a particular area/role your mentor can help you with?

We would like to match you with a mentor that can make a difference to your life and be there for you.

Thinking about what choice of mentor you would like please answer the following if you do not have a preference please leave blank.

Gender?

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Religion?
Hobbies/Interests - is there something that you would particularly like to have a joint interest in?
Do you have any further information that you wish to share that will be relevant to matching a mentor to you? i.e. any health issues or strategies to manage

Do you already receive support from any of the following?

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Required

How would you like your mentoring sessions carried out?

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Required

How often would you like to connect with your mentor?

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Required

I agree that the above information is correct and understand that a member of corporate parenting team will contact me.

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Required
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