Severn Mentoring – Referral & Enquiry Form

Providing alternative provision mentoring and tuition across Gloucestershire, Herefordshire and Monmouthshire.

Response within 3 working days

Section 1: Referrer Details

To be completed by the person making the referral.

Full Name

Role / Relationship to Learner

Organisation (if applicable)

Email Address

Phone Number

Digits, spaces and + ( ) - . allowed.

Preferred Contact Method

Type of Submission

Section 2: Learner Details

Learner Full Name

Date of Birth

Gender

Address

Local Authority

Current School / Provision (if applicable)

Year Group / Age

Parent/Carer Name

Parent/Carer Contact Number

Parent/Carer Email

Section 3: Background Information

Current situation / reason for referral

Key strengths and interests

Main areas of concern or support required

Has the learner been referred to or worked with any other services?

Yes No

If yes, please specify:

Section 4: Support Requested

Which pathway are you referring to?

Ages 6–15: Early Support Ages 16–25: Progression & Employment Unsure – please advise

Preferred provision type

1:1 Mentoring Tuition (Maths / English / Key Skills) Life Skills / Employability Mixed Support

Preferred days or frequency (if known)

Preferred start date

Section 5: Safeguarding & Additional Information

Current safeguarding concerns?

Yes No

If yes, please outline:

Designated Safeguarding Lead (if school referral)

EHCP or SEN support plan?

Yes No

Requires 1:1 supervision?

Yes No

Health conditions, allergies or medication needs?

Yes No

If yes, please specify:

Risk factors / known triggers (if any)

Section 6: Outcomes & Aims

What would you like the learner to achieve?

Section 7: Consent & Data Protection

By submitting, you confirm you have appropriate consent to share this information. Data will be stored securely in line with GDPR and Severn Mentoring’s Data Protection Policy. We will contact you about this referral.

Your Name (for consent)

Date

Upload documents (optional)

Attach EHCPs, plans, reports (Max 10MB per file).

Or email: referrals@severnmentoring.co.uk