Date:
|
|
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:
|
County:
|
Youth State:
|
Age Or Birth Month & Year (MM/YYYY):
|
Gender:
|
|
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:
|
|
Ethnicity preferred for Mentor:
|
|
This Mentor Ethnicity Required:
|
|
Does this child have a CASA?
|
CASA Name
|
CASA Email
|
CASA Phone
|
|
|
Do you want the youth to receive educational assistance from the mentor?
|
|
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?
|
|
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:
|
|
|
|
|
|
|
Please enter any additional information that would be helpful to the mentor:
|
|