CHILD REFERRAL FORM
Information on this form will be kept confidential and will be used to assist the staff in matching the child with an appropriate mentor.
Email address *
Date
MM
/
DD
/
YYYY
Referring person, agency
Address
City
Zip
Contact person
Title
Phone
Email address
Child's Data
Child's name
Date of birth
MM
/
DD
/
YYYY
Grade
Gender
Clear selection
Ethnic origin
Languages spoken at home
Parents' names
Guardians' names
Child living with
Relationship
Address
Home/ cell phone
Work phone
Place of work
Mobility of Child and Family
Does the child/ family move often
Clear selection
Does the child run away
Clear selection
Child/Family History
Is there a history of any of the following? (Check all that apply)
Please add any further information that may be helpful regarding this history.
Child's Self Esteem
What is the child’s attitude toward self?
Clear selection
School/ Education Information
School child is attending
Clear selection
Legal Data
Do you know of any other agencies working with this child?
Clear selection
Please list any of which you know
Recommendations for Matching
How do you think an adult mentor would help the child?
What type of person would you suggest we match with the child?
Other comments:
Any questions or concerns can be directed to executive director Amy Mondloch at executivedirector@kinshipcc.org or 262-204-3564.Thank you!
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