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Engaging Young People • Building Resilience • Creating Positive Futures

PROFESSIONAL REFERRAL FORM

Refer a young person for mentoring support

Please complete the form below to refer a young person aged 10–18 for mentoring through Norfolk Youth Mentoring.

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Provide as much relevant information as possible to help Jack understand the young person’s circumstances, current needs and the outcomes you hope mentoring may support.

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Submitting this form does not automatically confirm a placement. Jack will review the information and contact you to discuss suitability and the next steps.

Securely submitted • Enhanced DBS • Professionally reviewed • Young person focused

Before completing the referral, please ensure:

  • The young person and/or their parent or carer is aware of the referral, where appropriate

  • You have the necessary authority and consent to share the information provided

  • Any immediate safeguarding concerns have been managed through your organisation’s procedures

Allow approximately 10–15 minutes to complete the form.

Please have relevant contact, safeguarding and support information available before starting.

Professional Referral Form

Referrer Details

Date of Referral
Day
Month
Year

Young Persons Details

Date of Birth
Day
Month
Year

Referral Details

Current Areas of Concern
Has consent been provided by the young person and/or their parent/carer to make this referral?
Yes
No (If no please provide details below)
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Date
Day
Month
Year
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