Mentor Me - Youth Referral
Please fill out the following information about the child/youth being referred:
Child's Name: *
Your answer
Child's date of birth: *
Your answer
School child attends: *
Your answer
Grade: *
Your answer
Age *
Your answer
Gender
Ethnicity *
Please select all that apply: *
Required
Parent/Guardian's Name: *
Your answer
Parent/guardian speaks English *
Relationship to child? *
Your answer
Legal guardian? *
Address *
Your answer
Phone number *
Your answer
Email address:
Your answer
Employer:
Your answer
Person making this referral
Your answer
Contact information for person making referral
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Is the parent/guardian aware of the referral to Mentor Me? *
Reason for referral to Mentor Me (please be specific): *
Your answer
Child's current living situation? *
Your answer
If single parent- where is the absent parent? *
Your answer
If DJJ involvement, specify charge:
Your answer
If DFCS involvement, specific reason and brief history:
Your answer
Psychological disgnoses and/or developmental disability? Explain:
Your answer
Any drug/alcohol addictions? *
Anything else that would be helpful to know? *
Your answer
If yes, please explain:
Your answer
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