Please enable JavaScript in your browser to complete this form.A referral form for a Mentor has been received by The Hive. To ensure that we have all the most relevant up to date information on the young person, please complete this form. Should we be able to successfully match the young person, please ensure that you keep the Co-ordinator updated with any change of circumstances the Mentor will need to be made aware of, for example, a change of address.Email of parent/carer *EmailConfirm EmailName of young person *FirstLastAddress of young personAddress Line 1CityState / Province / RegionPostal CodeHas a risk assessment been undertaken on the young person that we need to be aware of? YesNoIf Yes – please provide details:Does the young person have a disability or any additional needs?YesNoIf Yes – please provide details: Does the young person have a statement of educational needs?YesNoIf Yes – who is the best person to contact about meeting these needs?Is the young person a risk to themselves?YesNoIf Yes – please provide details: Is the young person a risk to others?YesNoIf Yes – please provide details: Is there anybody the young person is not allowed to have contact with, without consultation with yourself?YesNoIf Yes – please provide more informationIs the young person aware of this?YesNoDo you have any further information you think the Mentor Co-ordinator should be made aware of to keep the young person and Mentor safe?YesNoIf Yes – please provide more information. Things to Consider: Mental Health concerns– Problems at home – Problems at school – Friendship concerns History of offending – History of alcohol & substance misuse - Risky behaviours – Behavioural plan – Ongoing medication.Things to Consider: Mental Health concerns– Problems at home, Problems at school, Friendship concerns, History of offending, History of alcohol & substance misuse, Risky behaviours, Behavioural plan, Ongoing medication.Please confirm below who you have consulted in the completion of this Risk Assessment.Name 1FirstLastRoleContact details Name 2FirstLastRole Contact details Name of person completing risk assessment: *FirstLastContact email address *Date Submit