Reach & Rise Youth Referral
Youth referrals can be made by parents/guardians, school counselors, teachers, mental health professionals, area agencies, other family members, or even youth themselves. Either the Reach & Rise 1:1 or Group Director will follow up to answer questions about the program and schedule a family meeting. Please bear in mind that the matching process takes time, and it may be up to several months before a youth is paired with an individual mentor or placed into a group. Although it is not necessary to fill out every question to make a referral, please make a best effort because it helps greatly in placement.

http://www.hsymca.org/Reach_And_Rise/
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Child's Information
Today's Date *
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Child's Name *
Gender *
Required
Age
Date of Birth *
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Street *
City *
Zip Code *
Parent/Guardian's Name *
Relationship to Child *
Home Number
Work Number
Cell Number
Email
Child's School
School City
Grade
Ethnicity (Optional)
Language Spoken by Child *
Required
Referral Information
Is this referral for 1:1 (one mentor with one child to meet weekly for one year) or for group (two mentors with a small group of up to 6 in a 16-week Fall/Spring or 8-week Summer session *
Name of Personal Making Referral *
Agency/Program/Relationship to Child
Phone(s) *
Email
Best Way to Be Contacted
Best Time to Be Contacted
Family Information
Child Lives With:
People Child Primarily Lives With (Name, Relationship, Age, Phone if Applicable)
Significant Others NOT Living in Household (Name, Relationship, Age, Phone if Applicable)
Language Spoken by Parent/Guardian
Is the child part of a military family?
Clear selection
Has a Child Protective Referral ever been made?
Clear selection
Referral Information
Reason(s) for Referral (Check all that apply) *
Required
Describe the reason(s) for the referral to the mentoring program.  Any recent changes with the child noticed?  Any recent changes with child’s family or living situation?  Any specific challenges or difficulties?  If so, what and when did they begin?    
What are some goals you think would be good for the child?  What could improve the child’s life?  
Describe the child (shy, outgoing, disruptive, etc.)
What would the child say is the reason she/he is being referred?  What would she/he see as a goal?
Is she/he on waiting list or enrolled in any other mentoring programs?
Any mentor preferences?  Male/female mentor (male mentors are only matched with male youth)?  Specific ethnicity or cultural background?      (Bear in mind there may be a longer wait to be matched 1:1 with male mentors due to a general shortage.) For group referrals, would the child benefit from a mix gender group with mix gender facilitators or from a group with the same gender participants and facilitators?
What are the days and/or times child is available to meet weekly with a mentor or group?
Has this referral been discussed with the child & parent/guardian? (If made by someone other than parent/guardian)?   If yes, when?  What was their response/are they interested in having a mentor for their child?
What are the child’s strengths?  What is she/he good at?   What are the child’s hobbies/interests?
School Information: What do the teachers say about the child?  How are his/her Grades?  Are there behavior problems?  Any previous SST Meetings? If yes, when?  Does child have an IEP or 504 Plan?  Ever been referred for special education?
Peer Relationships: How does child relate to peers?  Any significant relationships?  Any difficulties getting along well with peers?  Any specific age groups child relates best with?
Has family &/or child ever attended counseling?  If yes, where?  When?  For what reasons?  
Family History: Any changes/stressors for child/family (moves, deaths, births, remarriage, separations/divorces, witness any accidents, trauma, domestic violence, etc.)?  Who does child primarily live with? Any specific custody/visitation arrangements if parents are divorced/separated?  Who is most actively involved with the child? What are relationships between family members like?  
Are there any specific cultural issues for child/family that would be helpful to know?
Any serious past or present medical conditions, illnesses, injuries, surgeries, hospitalizations, ongoing treatment, etc. for child or family?  
Any history of substance use/abuse in family or with child?  If yes, what kind?   With what frequency
Any history of child or family members with suicidal thinking or suicide attempts?  If yes, when?  
Any history of child or family members with history of self-harm?  If yes, what & when?  
Any arrests, convictions, encounters for the child or family members with the law?  If yes, when & what happened?  Any Probation Officers worked with the child?  If yes, when?  Is this ongoing?   *
Any Child Protective Services &/or Police involvement with the child and/or family regarding child’s safety (e.g. physical, verbal/emotional, sexual, neglect, etc.)?  If so, when?  For What?  
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