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Mentee Referral
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Name of Youth
Your answer
Age
Your answer
DOB
MM
/
DD
/
YYYY
Gender
Your answer
Contact Information (Cell Phone, Email, Social Media)
Your answer
Current Living Arrangement (including city for mentor matching purposes)
Your answer
Education
Graduated High School
Enrolled in Online school
Enrolled in traditional school
Enrolled in college
No longer attends school and does not plan to
Other:
Clear selection
Unique Challenges (Mark all that apply, Add detail below)
Autistic
Learning Disability
Anger Management
Physical Disability
History of Trafficking
Substance Abuse/Addiction
Currently on Parole
Sexual Offender
Other
Please provide detail for any responses noted above. (While we don't need all of the specifics, we must be made aware of any potential for emotional or physical risk for the youth or the mentor paired with the youth.)
Your answer
What is awesome about this youth?
Your answer
What are some challenges for this youth? Triggers to avoid?
Your answer
Bridges Options
Hoping to qualify soon
Currently qualified and enrolled
No interest in the Bridges Program
Clear selection
Has the mentoring program been discussed with the youth?
Yes
No
Clear selection
What is the youth's level of interest in the mentoring program?
Very interested in having a mentor!
Possibly interested but wants to learn more about the program
Not very interested, but case worker would like program staff to follow up and share more about the program
Not at all interested in having a mentor
Clear selection
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