Make a Referral Referral Details WebReferral Service Detail Service:--None--Youth Mentoring Parent Mentoring Restorative Justice Self-referral Oberstown TR Oberstown Parent Whitetown 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) Whitetown Young Person or Parent’s (Mentee) Details *First Name *Last Name *Date of Birth: Gender:--None--Male Female Other 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 Whitetown 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 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: Type of weapon:--None--Firearm Knife Household Object DIY Tool Sword Other 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) --None--Unemployed Inactive - in education or training Inactive - not in education or training Employed Employment sub category:--None--Long termShort term Unable to answer question: ESF Education/Training (Setup) --None--Level 0 Primary Junior Cert Leaving Cert Tertiary/3rd Level 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?--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: Knife Crime: 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:--None--TR 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:
