FOR OFFICE USE ONLY:
MENTEE APPLICATION FORM
Please return the completed form to:
Izzy Neale
The Schofield Centre
Greenclose Lane
Loughborough
LE11 5AS
Tel No: 01509 236144
E-mail: izzy.neale@twentytwenty.org.uk
 Please complete all sections on this form to allow us to ensure that the young person
receives the most appropriate intervention
 Please complete referral criteria
 You must gain consent from parent (if young person is under 18) and young person
prior to making referral
 If a Advice/Warning Letter, Acceptable Behaviour Contract, Anti Social Behaviour Order
or other intervention is in place, please attach a copy to this form.
For Mentoring Scheme Use:
Form Received on __________________ (Date) by_____________________________
Accepted by______________________(mentor coordinator)
You will receive an email/call acknowledging that the form has been received.
Mentee name_______________________
Referrer___________________________
Acknowledgement sent:
Consent forms sent:
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 1
FOR OFFICE USE ONLY:
Message for Referrer’s
TwentyTwenty aims to support disadvantaged young people to realise their
potential. Our mentoring scheme is run almost entirely by volunteers from our
community who engage with young people to provide a positive adult role
model. Therefore, please be mindful that some young people due to the level of
support they require are not appropriate for this scheme.
If you have questions about referrals please contact 0300 111 2020.
All Referrals to TwentyTwenty’s Mentoring Scheme must fit the following
criteria:
 Risk of Anti-Social Behaviour & Crime
 NEET/At-risk of NEET
 Excluded or At-risk of Exclusion
Coordinators will assess each referral on a case by case basis. The
following determining factors are used to assess the suitability of a
referral.
Please tick all that apply
Determining Factors of Risks
 Family history of ASB & or Crime
 Individual or friends known to police or PCSO
 At-risk of School Exclusion or Attendance Less than 85%
 Vulnerable or Easily Influenced by others likely to lead to ASB/Crime
or leaving school with no or few qualifications
 Attending alternative provision off school site or part-time timetable/
Applied or Attending NEET provision (They must also fit one other
criteria above)
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 2
FOR OFFICE USE ONLY:
SECTION A–D TO BE COMPLETED BY YOUNG PERSON
SECTION A – YOUNG PERSON’S DETAILS
Name
Address
Postcode
Current age & DOB
Name of Parent /
Guardian
Telephone contacts
Parent/Guardian:
Young Person:
In School, Training,
Employment, or
none of the above.
Ethnicity
Provide brief details (If school see section B)
Do you have a physical disability, health issue or learning difficulty that affects your learning,
communication and/or understanding? Or undergoing assessment for a physical or learning
disability or difficulty?
No / Yes > Please specify:
What would you
like to do in the
future?
What are you
good at?
What do you
enjoy doing?
What do you want a mentor to help you with? Write your most important answer first
1………………………………………………………………………………………………………....
2………………………………………………………………………………………………………....
3………………………………………………………………………………………………………....
4………………………………………………………………………………………………………....
5………………………………………………………………………………………………………....
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 3
FOR OFFICE USE ONLY:
SECTION B – EDUCATIONAL/EMPLOYMENT DETAILS
Name of
School/College/Employer
Telephone Number
Main contact
Name:
Email:
Position:
OTHER PROFESSIONALS INVOVLED (i.e YISP, Impact, Prospects, Social Care, ASB
Team)
NAME
AGENCY
PHONE
EMAIL
SECTION C – RISK OF?
Please describe each situation in some detail.
Yes
No
Explain, how a mentor could help
I am at-risk of crime because I
am known to police.
I am at-risk of crime because
my Friends/Peers are involved
in crime or known to police.
I am at-risk of crime because
members of my family are
involved in crime or known to
police
I am at-risk of Exclusion?
Why?
I attend an alternative learning
provision or have a part-time
timetable?
Not in Education/Employment
or Training (NEET)
Attending a NEET Programme
Other?
_______________
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 4
FOR OFFICE USE ONLY:
SECTION C – Have you ever done anything that would be considered illegal and/or been
involved in Anti Social behaviour? (please tick)
Yes
No
Please give details if known:
Have you ever received: (tick all that apply)
 Dispersal Notice
 Advice Letter
 Warning Letter
 Acceptable Behaviour Contract
 Have you ever been convicted of a crime?
 Are you currently in court/awaiting court date?
SECTION D - CONFIRMATION
YOUNG PERSON’S SIGNATURE: __________________________________ Date: ________
SECTION E - CONSENT
Parental/Guardian Consent:
As the parent(s)/carer(s) of …………………………………………. we /I would like assistance from
the Mentoring Scheme
Signed………………………...........................
Date……………… OR
 Verbal consent
Date………………
THE NEXT SECTION IS TO BE COMPLETED BY THE
REFERRER
SECTION F – REFERRER’S DETAILS
Name
Agency/Organisation
Address
Telephone
Office:
Mobile:
E mail address
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 5
FOR OFFICE USE ONLY:
SECTION H - REASON FOR REFERRAL
In order to match young people with the right type of mentor we need to understand the
personality and background of the young person and those people who play a significant role
in their life.
Background on young person & family. Behaviour of young person in education and public
environment
ferrers signature:…………………………………….….….. Date: ……………………….
What do you hope for the young person to achieve through the Mentoring Project
Do you consider there to be any risks with working with this young person that the Twenty
Twenty Mentoring Scheme should be aware of? (Safety, matching with a male/female,
aggression, violence etc)
Thank you for completing the Referral Form.
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 6
FOR OFFICE USE ONLY:
TwentyTwenty Office Use only:
Coordinator Notes:
PRIMARY Reason for referral?
 Risk of ASB
 Risk of School Exclusion
 Risk of NEET
Mentoring Database
Checklist for Young People
Step 1 – Accepted Referrals
 New Mentee referral added to the student and
Referral tab (Administrator)
Step 2 – Matching Mentees
 Database number _________
 Mentee added to disability tab (Administrator)
Step 3 – Closing Mentees
 Coordinator completes Referral End Tab
The Schofield Centre, Greenclose Lane, Loughborough, LE11 5AS| 0300 111 2020 |mentor@twentytwenty.org.uk 7