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Le Chéile Referral Form

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:

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:

Residing with Other Note:

Household details

Who lives with the Person Referred?

Details of Any Issues in Family:

Offending Behaviour & Threats

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

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

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:

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:

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?

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:

Charity Number: CHY 17621

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Le Chéile Referral Form

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