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Youth Referral - Main Program
Youth Name:
*
Date
*
Date Format: MM slash DD slash YYYY
Date of Birth
*
Date Format: MM slash DD slash YYYY
Youth identifies as:
*
(You can click the text box below to give a description if you prefer.)
Male
Female
Grade:
*
School
*
Social Security # / Medical #
*
Insurance type and provider:
*
Who is making this referral?
*
Agency / Organization
Parent / Guardian
Name of referring agency / organization
*
Name of person making this referral
*
Phone number of person making this referral
*
Parent/Guardian:
*
Guardian's Phone number:
*
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Application Questions
What is the primary reason for this referral?
*
Why do you feel this youth might benefit from a mentor?
*
Why do you feel this youth might benefit from case management services?
*
Please list any current or recent legal history (diversion, committed, custody etc.):
*
Please list any incidents of violent or aggressive behavior:
*
Has youth been prescribed medication in the last 12 months?
*
Yes
No
Has youth received counseling / therapy in the last 12 months?
*
Yes
No
Describe current or recent mental health treatment:
*
Does the youth receive special education services? Type?
*
What other services or interventions are in place for the youth or family? Please list type of service and agency name:
*
What are the youth’s strengths & interests?
*
What strategies/learning models might be effective for a mentor working with this youth?
*
On a scale of 1–10 (10 being highest level) rate the youth’s level of:
Academic performance
*
Social skills
*
(forming/maintaining friendships, meeting new people, etc.)
Self-esteem
*
Family support
*
Communication skills
*
(written/verbal skills, expressing emotions, managing conflict, etc.)
Attitude about school/education
*
Peer relations
*
Will the youth & parent be receptive to mentoring AND case management?
*
How will the youth get to and from our program in Newport?
*
Parent/guardian
Friend or family member
Youth can walk / drive / take the bus
Youth needs assistance with transportation
What evenings can the youth attend?
*
Monday
Wednesday
Thursday
Additional comments
*
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