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Name of Youth
Contact Information (Cell Phone, Email, Social Media)
Current Living Arrangement (including city for mentor matching purposes)
Graduated High School
Enrolled in Online school
Enrolled in traditional school
Enrolled in college
No longer attends school and does not plan to
Unique Challenges (Mark all that apply, Add detail below)
History of Trafficking
Currently on Parole
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?
Hoping to qualify soon
Currently qualified and enrolled
No interest in the Bridges Program
Has the mentoring program been discussed with the youth?
What is the youth's level of interest in the mentoring program?
Very interested in having a mentor!
Possibly interested but wants to learn more about the program
Not very interested, but case worker would like program staff to follow up and share more about the program
Not at all interested in having a mentor
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