EmailMe Form - Mentee Referral to TeenWorks Mentoring

The goal of the TeenWorks Youth Mentoring Program is to provide hope for youth through one-on-one mentoring with a caring, reliable, adult friend. Our hope is that this program will enable them to engage in positive behaviors and create a support system in which to make appropriate decisions.
The following information is to be completed by the referring agency, family member or TeenWorks partner. It is important that the person within the agency/organization who is best acquainted with the youth complete the information. The information obtained will help us identify and evaluate the needs of the youth and allow the best matching with a mentor.

Referring Party: Agency/Organization/Family Member *

Name of Referring Individual/Officer *

Referring Party's Email *

Address of Referring Entity *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone of Referring Entity *

### - ### - ####

Name of Youth: *

First Last

Sex: *

Male

Female

Youth's "At-Risk" Factors (check all that apply) *

Youth's Date of Birth *

School and Grade

Primary Caregiver *

Name of Primary Caregiver *

First Last

Address of Primary Caregiver *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone of Primary Caregiver *

### - ### - ####

Names, Relationship (and age, if known) of all others in youth's household *

Does the youth have any learning disabilities? *

Yes

No

Unknown

If yes, describe type of disability

Rate the Youth's Personal Characteristics

On a scale of 1-10 (1=lowest, 10=highest) rate the youth's level of....

Academic Performance *

Social Skills *

Self-esteem *

Family Support *

Communication Skills *

Attitude Toward School/Education *

Peer Relationships *

Attitude Toward Authority *

Emotional Stability *

Sexual Adjustment *

Positive Relationships *

Problem-solving Skills *

Setting/Accomplishing Goals *

Does the youth adapt well to new situations? *

Yes

No

Don't know

Is the youth performing at full potential at school? *

Yes

No

Don't know

Does the youth participate well in group situations? *

Yes

No

Don't know

Does the youth have hobbies or interests? *

Yes

No

Don't know

If yes, describe below:

Describe hobbies or special interests:

Does the youth know how to seek attention without acting out? *

Yes

No

Don't know

Please list any health issues

Does the youth have a history of trauma? *

Yes

No

Don't know

What other agencies are involved with this youth?

Substance Abuse Issues *

Parental/Guardian Issues *

Why do you feel that this youth would benefit from a mentor?

Please list any additional insight that you feel may be beneficial in successfully matching this youth:

Today's Date *

MM / DD / YYYY