Mentee Referral Form (To Be Filled out by Client Manager)

Mentee Referral Form (to be filled out by Client Manager)

*Please refer to attached eligibility criteria prior to completing referral.

Client Manager/Parole Officer Information

Name: / Phone Number:
E-Mail: / Region:

Client Information

Name: / DOB: / Grade:
Ethnicity: / Treatment Program & Phone number:
Estimated Release Date: / Trails Number:
Committing Offense:
Outstanding Warrants / Court cases:

Estimated Parole Plan (CRB, Step Down, Transition Living, Home, School)

Legal Guardian Information

Legal Guardian:
Print Last Name, First Name / Relationship
Legal Guardian:
Print Last Name, First Name / Relationship
Print Current Address / Best Phone Number
Email:

Will client be returning home upon release? Yes No

Reason for Referral and desired goals/outcomes for mentoring:

In your professional opinion, what are some of the youth’s assets or strengths?

Health Information:(Please inform client and guardian prior to submitting this information.)

Physical Challenges: Yes No

Describe/Information:

Substance Abuse (current or history):

Yes No

Currently in treatment? Yes No

Teen Parent: Yes No

Children (ages)

Psychological/Mental Health:

Yes No

Diagnosis:

(to be shared by TP to Mentor)

Medications:
What are they for?

Suicidal ideation/attempts:

Yes No

Last Attempt:
Treatment (current/past)/Any additional information
Abuse/Neglect History:

Physical Abuse: (check all that apply)

Victim Aggressor Witness N/A

At what age:

Perpetrator:

Sexual Abuse/Rape:

Victim Aggressor Witness N/A

At what age:

Perpetrator:

Domestic Violence:

Victim Aggressor Witness N/A

At what age:

Perpetrator:

Client Manager: ______

Date

Treatment Provider: ______

Date

Dear Parents/Guardians:

[Include a paragraph about the success of your chapter and a brief history]

Mentoring has been utilized by YFC as a method for addressing the profound challenges faced by program participants through creating the opportunity for them to interact with loving and responsible adults who are committed to fostering positive life-changing influences for these young people. It is our fundamental belief and strategy that the successfulness of a mentee is best achieved when a significant investment of resources is made in the mentor and the mentee/mentor relationship.

Name of youth referred to YFC: ______

Having read the above information I, ______

Printed Name of Parent(s)/legal Guardian(s)

give permission for ______to participate in the YFC

Printed Child’s Name

mentoring program. (for at least 12 months)

(Please INITIAL Yes or No to the following.)

I give permission for the above named child to ride in his mentor’s vehicle and to be transported to and/or from YFC events/activities with a staff member or approved volunteer. ______Yes ______No

I authorize the release of the above named child’s DYC Assessment, Parole Plan, Discharge Reports, MBTP Feedback sheets, and CJRA. All information is kept strictly confidential and shared to provide the best match for a mentor.

______Yes ______No

I give my permission for communication with the above named child’s Client Manger/Parole Officer, GAL, Treatment Provider, Unit Manager, and any other professionals who may be of assistance to provide the best possible service.

______Yes ______No

I authorize permission for above named child to appear in photos for YFC’s publicity or promotional purposes. ______Yes ______No

I authorize permission for above named child to participate in interview process to best match a mentor and continued evaluation once mentor match is made.

______Yes ______No

*This authorization can be revoked at anytime by providing written documentation to YFC. However, any information that was released prior to the revocation may be used for the purposes listed above. Authorization is valid from the date of your signature below until two (2) years from the date of your signature below, unless other wise stated here.

______

Signature of parent(s)/legal guardian(s) Phone number Date

[include chapter’s contact information]