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.
* Required
Email address
*
Your email
Date
MM
/
DD
/
YYYY
Referring person, agency
Your answer
Address
Your answer
City
Your answer
Zip
Your answer
Contact person
Your answer
Title
Your answer
Phone
Your answer
Email address
Your answer
Child's Data
Child's name
Your answer
Date of birth
MM
/
DD
/
YYYY
Grade
Your answer
Gender
Female
Male
unspecified
Clear selection
Ethnic origin
Your answer
Languages spoken at home
Your answer
Parents' names
Your answer
Guardians' names
Your answer
Child living with
Your answer
Relationship
Your answer
Address
Your answer
Home/ cell phone
Your answer
Work phone
Your answer
Place of work
Your answer
Mobility of Child and Family
Does the child/ family move often
Yes
No
Clear selection
Does the child run away
Yes
No
Clear selection
Child/Family History
Is there a history of any of the following? (Check all that apply)
Physical abuse
Sexual Abuse
Suicidal Tendencies
Mental Health Issues
Neglect
Chem. Dependency/Alcoholism
Physical Disability/Illness
Rape/Teen pregnancy
Other:
Please add any further information that may be helpful regarding this history.
Your answer
Child's Self Esteem
What is the child’s attitude toward self?
Very good
Good
Fair
Poor
Clear selection
School/ Education Information
School child is attending
Arlington Elementary
Cambria Friesland Elementary
Cambria Friesland Middle/ High
Columbus Elementary
Columbus High
Columbus Intermediate
Columbus Middle
Discovery Charter School
Fall River Elementary
Fall River High
Lewiston Elementary
Lodi Elementary
Lodi High
Lodi Middle
Lodi Primary
Muir Elementary
Ouisconsing School of Collaboration
Pardeeville Elementary
Pardeeville High
Pardeeville Middle
Petersen Elementary
Portage Academy of Achievement
Portage High
Poynette Elementary
Poynette High
Poynette Middle
Randolph Christian
Rio Elementary
Rio Middle/ High
Rusch Elementary
Spring Hill Elementary
Spring Hill Middle
St. Jerome
St. John’s Lutheran
St. Mary’s
Trinity Lutheran
Wayne Bartels Middle
Wisconsin Academy
Wisconsin Dells High
Woodridge Elementary
Zion Evangelical Lutheran
Other:
Clear selection
Legal Data
Do you know of any other agencies working with this child?
Yes
No
Clear selection
Please list any of which you know
Your answer
Recommendations for Matching
How do you think an adult mentor would help the child?
Your answer
What type of person would you suggest we match with the child?
Your answer
Other comments:
Your answer
Any questions or concerns can be directed to executive director Amy Mondloch at executivedirector@kinshipcc.org or 262-204-3564.Thank you!
Send me a copy of my responses.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Kinship Mentoring of Columbia County. Inc.
Report Abuse
Forms
