***Menslink Mentoring is for males aged 13–18, who are in need of a reliable adult male role model. Menslink Counselling is for males aged 12- 25 who are in need of a supportive counsellor***
****IN REGARDS TO MENTORING: Please be aware that due to limited spaces we will give priority to young men who have little or no contact with their father.****

* 2. Young man's name

* 3. Current age (please check age requirements above)

* 4. Young man's contact number

* 7. School attended?

* 8. Parent/guardian name?

* 9. Parent/guardian contact number (if client is under 18)?

* 13. Has the young person ever been affected by any of the following?

* 14. Please indicate if they have ever been affected by:

  Direct victim Indirect victim / witness Perpetrator
Physical violence 
Psychological / emotional abuse (e.g. verbal abuse, intimidation, control)
Sexual abuse
Psychological / emotional violence (e.g. verbal abuse, intimidation, control)

* 15. Please indicate whether client has been affected by any of the following:

* 16. In which areas do you hope Menslink's services will impact positively?

  Low priority Medium priority High priority
Confidence & self-esteem
General happiness
Peer relationships
Relationships with family members
Taking responsibility for actions
Ability to manage emotions (e.g anger)
Willingness to try new things
General demeanour & attitude
Dependence on video games
School engagement
Decision making

* 17. Name of person providing referral

* 18. Relationship to client

* 19. Name of agency or school making referral

* 20. Phone number of referrer

* 21. Email

* 22. Please provide the reason for your referral including background on the client

* 23. Is there anything else, including any legal issues we should be aware of?

* 25. By ticking this box I consent to Menslink collecting personal data for anonymous statistical purposes and storing this information offshore.