Youth Referral Youth Name:*Date* Date of Birth* Youth identifies as:*(You can click the text box below to give a description if you prefer.)MaleFemaleGrade:*School*Social Security # / Medical #*Insurance type and provider:*Who is making this referral?*Agency / OrganizationParent / GuardianName 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 QuestionsWhat 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?*YesNoHas youth received counseling / therapy in the last 12 months?*YesNoDescribe 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*Self-esteem*Family support*Communication skills*Attitude about school/education*Peer relations*Will the youth & parent be receptive to mentoring AND case management?*Can the parent assist in transportation to the program?*What evenings can the youth attend?* Monday Wednesday Thursday Additional comments*
