Heart Gallery Mentor Program
Youth Referral Form
Use this form to recommend that a mentor be found for a youth.
Red fields are required.Please fill in-order. Thanks!

Your relationship to the youth:
Please Specify
Your Role At School:

Your Name:
Your Home/Work Address:
Your Home/Work City:
Your Home/Work State:
Home/Work County:
Home/Work Phone Number:
Your Cell Number:
Your Email:

Caseworker (First, Last) Name:
Caseworker Phone:
Caseworker Email:

Would you like to be at the match with the mentor and the youth?
Supervisor (First, Last) Name:
Supervisor Phone:
Supervisor Email:
Is this youth in foster care?
Parent/Family (First, Last) Name:
Home Address:
Home City:
Home State:
Home County:
Home Phone Number:
Parent Cell Number:
Parent Email:
Other Parent Contact Info
(best time to call, others in residence, other details):
Foster Parent (First, Last) Name(s):

Is This a Relative Placement?
Relationship of caregiver:
Foster Parent Phone:
Foster Parent Address:
Foster Parent City:
Foster Parent State:
Foster Parent County:
Foster Parent Email:
Foster Parent Contact Info
(best time to call, others in residence, other info):
Youth Name:
Youth State:
Age Or
Birth Month & Year (MM/YYYY):

His/Her Own Phone (if available):
Youth Address:
(only if different)
Youth City:
(only if different)
Other Contact Info:
Primary Language
(if other than English):

Ethnicity preferred for Mentor:

This Mentor Ethnicity Required:
Does this child have a CASA?
CASA Email
CASA Phone
Do you want the youth to receive educational assistance from the mentor?
      Allows mentors to connect with the child's school in order to help them academically.
What school does the youth attend and what grade is she in?
Does the youth see a therapist regularly?

If any of the following can provide guidance for mentor,
and you have contact information, please check below:

School Counselor First/Last Name
School Counselor Phone
School Counselor Email
School Counselor Organization
School Program Administrator First/Last Name
School Program Administrator Phone
School Program Administrator Email
School Program Administrator Organization
Principal / Vice Principal First/Last Name
Principal / Vice Principal Phone
Principal / Vice Principal Email
Principal / Vice Principal Organization
School Psychologist First/Last Name
School Psychologist Phone
School Psychologist Email
School Psychologist Organization
Tutor First/Last Name
Tutor Phone
Tutor Email
Tutor Organization
Coach First/Last Name
Coach Phone
Coach Email
Coach Organization
IEP / Special Ed Teacher First/Last Name
IEP / Special Ed Teacher Phone
IEP / Special Ed Teacher Email
IEP / Special Ed Teacher Organization
Nurse First/Last Name
Nurse Phone
Nurse Email
Nurse Organization
Teacher First/Last Name
Teacher Phone
Teacher Email
Teacher Organization
Therapist First/Last Name
Therapist Phone
Therapist Email
Do you want the youth to participate in life skills training?
      Mentors and children attend regular classes and are given a curriculum covering basic life skills.
Has this youth been adjudicated?
If yes, please describe:
Can youth have photo taken?
If child wants a photo, and you have legal responsibility for consent, do you give A Family For Every Child permission to take photos of this youth to use the image in promoting the mentor program?
Can youth have video taken?
Is the youth legally free?
What is the case plan for the child? Where do you see it heading?
Can you tell us a little about the characteristics which make this child special?
Are the parent(s) of this child incarcerated?
If so, which parent?
Since you know the youth and her preferences, can you give us general guidance? We anticipate interviewing the youth to become more familiar with her. Help us to ask the right questions! Can you relate any relevant events in the youth's history?
Why might you recommend a mentor? What benefits do you foresee from having a mentor in the youth's life? If you anticipate that she will have certain positive experiences or you have particular expectations, this is a good place to mention those...
Does she like school?
What is her favorite subjects in school?
What is her least favorite subject in school?
What subject her most challenging in school?
What is her type of favorite food?
What types of outdoor activities does she like?
Do she like to read? Which books?
Are there indoor activities that she wants to try?
Does she participate in sports? Which ones?
Do you have any idea what she would like to be when she grows up?
What do you think this mentor should already know about?
Is there anything that she wants to learn or have lessons about?
What animals does she like or would she like?
What type of movies does she like?
What makes her embarrassed or scared?
What type of mentor would she like?
Please check below up to 5 of the youth's known interests or activities:
Other interests and hobbies:
Additional Notes: Are there any behaviors or safety concerns that a mentor should be aware of? Please provide as much as you would like the mentor to know that would be helpful in relating to the youth.
Please enter any additional information that would be helpful to the mentor: