Mentoring Project Referral form
Please complete and submit this form together with your client/member/patient. You can alternatively send it by post to: Borderlands Mentoring Project, The Assisi Centre, Lawfords Gate, Bristol, BS5 0RE.  If you have any queries about this form or the Mentoring project, please call the mentoring manager, Susanna on 07713 695 845. Please make sure you read the guide to referrers before submitting the referral.
Thank you and look forward to working with you.

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Email *
Referral date
MM
/
DD
/
YYYY
Mentees details
First and last name
Borderlands Member number
Phone number
Level of English
Clear selection
Date of arrival to Bristol and current address
First language
Immigration status
Clear selection
If other, please specify
Gender
Age
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
AM
PM
Evening
Purpose of mentoring. Please when completing this section make sure to think about practical goals (eg finding volunteering opportunities, get to know Bristol, improve English, access services or social activities, etc) as well as emotional goals (eg increase confidence)
Any additional information regarding language requirements or particular needs
Do you confirm that the client have sufficient English to engage in a mentoring scheme without interpreters
Clear selection
Do you confirm that the client understand that Susanna from Borderlands will contact them for further information
Name of organisation and of referrer, telephone and email
Submit
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