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Le Chéile Referral Form
Referral Details
WebReferral
Service Detail
*Service:
--None--
Youth Mentoring
Parent Mentoring
Restorative Justice
*Region (Referrals/Cases):
--None--
Dublin North
Dublin South
Meath
Cork North & East
Cork South & West
Limerick and Clare
Midlands and Kildare
South East
Oberstown
GYDP - Dublin
GYDP - South East
RJ (Limerick)
Young Person or Parent’s (Mentee) Details
*First Name
*Last Name
*Date of Birth:
Gender:
--None--
Male
Female
Ethnic Group:
--None--
White Irish
White Irish Traveller
Any other white Background
Roma
Black or Black Irish: African
Black or Black Irish: Any other Black background
Asian or Asian Irish: Chinese
Asian or Asian Irish: Any other Asian background
Other, including mixed background (write in description)
If other:
Nationality:
--None--
Irish
British
Polish
Romanian
----------------------
Afghan
Albanian
Algerian
American
Andorran
Angolan
Antiguans
Argentinean
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Barbudans
Batswana
Belarusian
Belgian
Belizean
Beninese
Bhutanese
Bolivian
Bosnian
Brazilian
Bruneian
Bulgarian
Burkinabe
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Central African
Chadian
Chilean
Chinese
Colombian
Comoran
Congolese
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Djibouti
Dominican
Dutch
East Timorese
Ecuadorean
Egyptian
Emirian
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
Ghanaian
Greek
Grenadian
Guatemalan
Guinea-Bissauan
Guinean
Guyanese
Haitian
Herzegovinian
Honduran
Hungarian
I-Kiribati
Icelander
Indian
Indonesian
Iranian
Iraqi
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakhstani
Kenyan
Kittian and Nevisian
Kuwaiti
Kyrgyz
Laotian
Latvian
Lebanese
Liberian
Libyan
Liechtensteiner
Lithuanian
Luxembourger
Macedonian
Malagasy
Malawian
Malaysian
Maldivan
Malian
Maltese
Marshallese
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monacan
Mongolian
Moroccan
Mosotho
Motswana
Mozambican
Namibian
Nauruan
Nepalese
New Zealander
Ni-Vanuatu
Nicaraguan
Nigerian
Nigerien
North Korean
Northern Irish
Norwegian
Omani
Pakistani
Palauan
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Portuguese
Qatari
Russian
Rwandan
Saint Lucian
Salvadoran
Samoan
San Marinese
Sao Tomean
Saudi
Scottish
Senegalese
Serbian
Seychellois
Sierra Leonean
Singaporean
Slovakian
Slovenian
Solomon Islander
Somali
South African
South Korean
Spanish
Sri Lankan
Sudanese
Surinamer
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian or Tobagonian
Tunisian
Turkish
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbekistani
Venezuelan
Vietnamese
Welsh
Yemenite
Zambian
Zimbabwean
Nationality Other Note:
Referral Details
*Referrer First Name:
*Referrer Last Name:
*Referrer Email:
*Referrer Mobile:
*Referral Agency:
--None--
Probation
GYDP - Dublin
GYDP - South East
JLO
Oberstown/Detention
Other
Referral Agency Other Note:
Status with Referral Agency
Adjourned Supervision:
Initial Assessment PSR Stage:
Mentor Order:
Probation Bond:
Juvenile Liaison Programme:
Probation Order with Mentoring:
Parent Mentoring Referral:
Status with Referral Agency Other:
Length of Order/Sentence (Months):
Mentee Contact Details
*Street
Area/Town
*City/County
Eircode
Phone
Mobile
Email
Residing with Details
Parent/Contact Name:
Parent/Contact Address:
Parent/Contact Number:
Residing With:
--None--
Parent(s)
Residential Unit
Extended Family
Foster Care
Treatment Centre
Detention Centre
Supported Lodgings
Other
Other (Parent Mentoring Referral)
Residing with Other Note:
Household details
Who lives with the Person Referred?
Details of Any Issues in Family:
Offending Behaviour & Threats
No Offence:
Arson:
Assault Section 2:
Assault Section 3:
Attempted Robbery:
Burglary:
Criminal Damage:
Drunk & Disorderly:
Intoxicated:
Road Traffic (Driver):
Road Traffic (Other):
Possession of drugs for own use:
Possession of drugs for sale & supply:
Public Order:
Handling of Stolen Property:
Robbery:
Theft:
Trespass:
Possession of a Weapon:
Offending Behaviour Parent Mentoring Referral:
Offending Behaviour & Threats:
Please give details of any offences (current or previous) which involve Threatening, Abusive, Insulting behaviour; Assault or Possession of a Weapon, Robbery (any offence which includes violence against a person):
Is the person under threat from others:
--None--
Yes
No
Substance Use
Alcohol:
Cigarettes:
Cocaine:
Ecstasy:
Heroin:
LSD:
Marijuana:
Solvents:
Prescribed Medication:
Benzodiazepines:
Note on Other Substance Use:
Not Known:
Medical History
Known medical conditions, physical or mental health issues? (including history of depression, self-harm, suicidal ideation or attempts):
Learning Difficulties
Literacy:
Dyslexia:
ADHD/ADD:
Numeracy:
Autistic Spectrum:
Other Learning Difficulty:
Note on Other Learning Difficulties:
Health and Safety
Are there any areas from your Health & Safety Risk Assessment that Le Chéile should be aware of?
--None--
Yes
No
Do you consider the person to pose a risk to themselves or their Mentor?
--None--
Yes
No
Health and Safety Details (if yes):
Reason for Referral
Please outline why you are referring the person for mentoring and the benefits you hope they will gain from it:
Any Additional Information
Please give any other relevant information about the young person which may be helpful for Le Chéile to be aware of:
Have you discussed Le Chéile’s mentoring/RJ service with the young person or parent:
--None--
Yes
No
For Mentoring referrals: Mentoring involves a person meeting a trained volunteer on a one-to-one basis in their local community on a regular basis. Do you consider the person to be suitable for mentoring?
--None--
Yes
No
Details if not suitable:
European Structural Fund (ESF) Criteria - Labour Market
ESF Labour Market (Setup)
Employed:
Unemployed:
Inactive:
Unable to answer question:
ESF Education/Training (Setup)
Level 0:
Primary:
Junior Cert:
Leaving Cert:
Tertiary/3rd Level:
Unknown (Edu/Trg):
European Structural Fund (ESF) Criteria - Disadvantage
1. Jobless Household:
2. Jobless Household & dependent children:
3. Single parent household:
4. Migrant/foreign background/minority:
5. Disabled:
6. From rural area:
7. Homeless or affected by housing exclusion:
8. Other disadvantage:
--None--
Yes
No
9. Level 0 education and above aged 12:
10. Offender:
11. At risk of offending:
Restorative Justice Referrals Only
Have you completed the RJ suitability and screening form?
--None--
Yes
No
Model of Restorative Justice the young person is being referred for
Victim/Offender Mediation:
Victim Impact Panel:
Victim Empathy Programme:
Reparation:
Conferencing:
Reason for referral and model chosen:
RJ Approx Start date:
RJ Approx End date: