Mentee Referral
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Name of Youth
Age
DOB
MM
/
DD
/
YYYY
Gender
Contact Information (Cell Phone, Email, Social Media)
Current Living Arrangement (including city for mentor matching purposes)
Education
Clear selection
Unique Challenges (Mark all that apply, Add detail below)
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.)
What is awesome about this youth?
What are some challenges for this youth? Triggers to avoid?
Bridges Options
Clear selection
Has the mentoring program been discussed with the youth?
Clear selection
What is the youth's level of interest in the mentoring program?
Clear selection
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