Referral Form | Le Chéile Mentoring

Tel: 01 214 4350 – Email: info@lecheile.ie

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Service Detail

Service:

Region (Referrals/Cases):

Young Person or Parent’s (Mentee) Details

*First Name

*Last Name

*Date of Birth:

Gender:

Ethnic Group:

If other:

Nationality:

Nationality Other Note:

Referral Details

*Referrer First Name:

*Referrer Last Name:

*Referrer Email:

*Referrer Mobile:

Referral Agency:

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:

Detention and Supervision Order:

Status with Referral Agency Other:

Length of Order/Sentence (Months):

Mentee Contact Details

*Street

Area/Town

*City/County

Eircode

Phone

Mobile

Email

Parent/Carer Contact Details

Parent/Contact Name:

Parent/Contact Address:

Parent/Contact Number:

Relationship to person:

Residing With:

Residing with Other Note:

Household details

Who else lives with the Person Referred?

Highlight strengths and challenges 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:

Type of weapon:

Sexual Offences:

Money Laundering:

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:

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?

Do you consider the person to pose a risk to themselves or their Mentor?

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

Is the person involved in education/training/employment currently?

Education training employment details:

Is the person currently involved in other services?

Other services details:

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:

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?

Details if not suitable:

Restorative Intervention Initial Suitability Screening

Guilty Plea:
No Plea Full Admission:
Partial Acceptance Undermines Process:
Restorative Approaches Explained:
Further Assessment Willing/Agreeable?:
Referred Person appears motivated?:
Issues pertaining to Victim?:
Issues pertaining to Victim - Details:
Other concerns of any nature?:
Other concerns details:

Suitable for further assessment?:
Checklist Completed by:

Restorative Justice Referrals Only

Victim/Offender Mediation:
Reparation:
Victim Empathy Programme:
Restorative Justice Meeting:
Reason for referral and model chosen:
RJ Approx Start date:
RJ Approx End date:

Oberstown Temporary Release Only

Detention Start Date:

Detention End Date:

Period of Temporary Release:

Order Upon Release:

Significant Relationships:

Achievements & Strengths:

Child Protection Register:

Additional Information:

Name of Key Worker:

Phone Contact for Key Worker:

Email Contact for Key Worker:

Name of Probation Officer on Release:

Phone Contact for Probation Officer:

Email Contact for Probation Officer:

Allocated Social Worker:

Name of Social Worker:

Phone Contact for Social Worker:

Other Agencies Involved:

Data Protection

By submitting this form, you are confirming that you have fulfilled the obligations placed on the collection and processing of personal and special category personal data as outlined by GDPR and that the data submitted to Le Cheile in this form has been collected and processed in compliance with GDPR.

Contact us

Le Chéile Mentoring,
24 Tivoli Terrace South,
Dún Laoghaire,
Co. Dublin.
Tel: 01 214 4350
Email: info@lecheile.ie

Media: josephinegibney@lecheile.ie

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