Alias

Date of Birth

Gender–None–MaleFemaleIntersex

Cultural Background–None–AustralianAboriginal and Torres Strait IslanderPacific IslanderVietnameseOtherAboriginalTorres Strait IslanderNeither Aboriginal or Torres Strait Islander
Program Eligibility (Client must answer yes to all):
The Mentee is at risk of custodial sentence?

The Mentee is voluntarily seeking support?

The Mentee is currently living in the Sydney Metropolitan / Western Suburbs area?

The Mentee is aged 14-25?

Mentee’s current living situation:
What is the Mentee’s current living situation?–None–Private rentalTransitional centreAOD rehabilitationCorrectional centreCrisis accomodationTemporary accomodationHomelessHousing NSW propertyHome with biological parent/sHome of relativeResidential careStaying at friends houseTransitional careOther

Is the Mentee regularly attending school?–None–YesNo

Client Information:

(In your view why is this Mentee at risk of being affected by the Criminal Justice System?):
In contact with the CJS

Received a caution

Been arrested

How would this Mentee benefit from a mentor?

Referrer’s Details:

Referrer’s First Name

Referrer’s Last Name

Referrer’s Organisation:

Referrer’s Position

Referrer’s Phone

Referrer’s Email

Is this Mentee aware that the referral is being made?