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Brave Beginnings Mentee Referral Form
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Referring Shelter
Your answer
Referrer's Name
Your answer
Potential Mentee Information
Include any relevant details
Name of Referral
Your answer
Referral's phone number
Your answer
Referral's email
Your answer
Does she have children?
Your answer
Is she out of crisis/danger?
Yes
No
Clear selection
Briefly describe the referral's history. What sort of abuse did she face and what is her story?
Your answer
Has the referral ceased contact with the abuser? How long has she ceased contact for?
Your answer
Is the referral in or out of a shelter?
In
Out
Other:
Clear selection
What do you believe to be the referral's current life goals? For example, are they looking to re-enroll in school or find work in a particular industry?
Your answer
Does the referral have easy access to technology? Brave Beginnings is an online program requiring participants to be able to access video conferencing services
Your answer
Is there anything else we should know about the referral that would affect her ability to participate in the Brave Beginnings program?
Your answer
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