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/
Child's Information
Today's Date *
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Child's Name *
Your answer
Gender *
Required
Age
Your answer
Date of Birth *
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Street *
Your answer
City *
Your answer
Zip Code *
Your answer
Parent/Guardian's Name *
Your answer
Relationship to Child *
Your answer
Home Number
Your answer
Work Number
Your answer
Cell Number
Your answer
Email
Your answer
Child's School
Your answer
School City
Your answer
Grade
Your answer
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 *
Your answer
Agency/Program/Relationship to Child
Your answer
Phone(s) *
Your answer
Email
Your answer
Best Way to Be Contacted
Best Time to Be Contacted
Your answer
Family Information
Child Lives With:
People Child Primarily Lives With (Name, Relationship, Age, Phone if Applicable)
Your answer
Significant Others NOT Living in Household (Name, Relationship, Age, Phone if Applicable)
Your answer
Language Spoken by Parent/Guardian
Is the child part of a military family?
Has a Child Protective Referral ever been made?
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?
Your answer
What are some goals you think would be good for the child? What could improve the child’s life?
Your answer
Describe the child (shy, outgoing, disruptive, etc.)
Your answer
What would the child say is the reason she/he is being referred? What would she/he see as a goal?
Your answer
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?
Your answer
What are the days and/or times child is available to meet weekly with a mentor or group?
Your answer
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?
Your answer
What are the child’s strengths? What is she/he good at? What are the child’s hobbies/interests?
Your answer
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?
Your answer
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?
Your answer
Has family &/or child ever attended counseling? If yes, where? When? For what reasons?
Your answer
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?
Your answer
Do you have any experience running or facilitating a group/team? Are there any specific cultural issues for child/family that would be helpful to know?
Your answer
Any serious past or present medical conditions, illnesses, injuries, surgeries, hospitalizations, ongoing treatment, etc. for child or family?
Your answer
Any history of substance use/abuse in family or with child? If yes, what kind? With what frequency
Your answer
Any history of child or family members with suicidal thinking or suicide attempts? If yes, when?
Your answer
Any history of child or family members with history of self-harm? If yes, what & when?
Your answer
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? *
Your answer
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?
Your answer
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