Flourish One-to-One Mentoring Request Form
Please fill in this form with as much detail as you can in order for us to find out how we can best support your young person.
Email *
Date of this referral *
MM
/
DD
/
YYYY
Where did you hear about Flourish Mentoring?
First name of young person *
Last name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Young person's address (house name/number and street) *
Young person's address (town or village) *
Young person's address (address line 3)
Young person's address (postcode) *
Parent / Carer name *
Parent / Carer phone *
Parent / Carer email *
School/college *
Year group *
What is the young person's level of attendance at school (approximate %)?
Has the young person agreed to have a mentor? *
(If you have asked them), please ask the young person to describe here why they would like a mentor:
What are your main concerns for this young person? *
What outcomes do you hope to see as a result of the mentoring? *
Do any of the following apply to this young person?
Please give details if you answered yes to any of the above. For example if 'yes' to special educational/additional needs, what are these? If 'yes' to other therapies/interventions in place, what is the therapy/intervention and who provides this. Please include contact details of a social worker and/or CAMHS clinician if appropriate.
Please tell us about any risks observed or known in the last 6 months:
Please give details if you answered 'yes' to any of the above:
Name of the person making this referral *
Are you (Please choose)... *
Required
Please state your role/relationship to the young person. *
Name and email of school staff member to contact (if you wish for us to enquire about providing the sessions in school).
Phone number of school staff member.
How much are you willing to contribute to sessions in total? *
Value for 12 sessions is £396, any full or part contribution is very gratefully received to help us keep our work going to support more girls. Please note we would be honoured to support, even if you feel you cannot contribute financially.
When we launch new services and opportunities for girls, we'd like to be able to let you know. Are you happy for us to contact you in the future? (We won't inundate you by any means!) Please indicate if you are happy for us to contact you via (tick all that apply): *
Required
Thank you!
For your information, following receipt of your referral, we will:

- carry out a risk assessment within one month
- give a response and if appropriate match the young person with a mentor, giving a guide as to when mentoring can begin

Factors that may influence Flourish's ability to provide mentoring include mentor capacity and level of need. We may suggest alternative support where appropriate.

Please note that Flourish support begins at the first mentoring session, and we will be committed to supporting girls in the most appropriate ways from this point. Whilst girls are waiting to be matched with a mentor, or whilst arrangements are being made for the sessions to start, we regret that we cannot take responsibility or accept liability for their well-being. If circumstances change or different support is required, please remain vigilant as a parent, carer, GP, school staff member or other referrer whilst the matching process takes place or the young person is on a wait list.

If you have any questions or wish to discuss the request further, please contact us at hello@youcanflourish.co.uk or call 07732 825721.
Submit
Never submit passwords through Google Forms.
This form was created inside of Flourish. Report Abuse