Youth Mentoring Referral Form

Contact Info

Contact information for the person referring a child or children to People Places.

First Name *

Last Name *

Referral Date *

Local Department of Social Services Agency *

Contact Phone Number *

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

Funding Status

Date of Approval or Anticipated Approval

Hours Approved or Requested

Upload Funding Approval Document – in order to begin services a copy of funding paperwork needs to be received.

Maximum upload size: 516MB

Client’s Current Parents/ Caretakers

Name(s)

Address

Email

Phone

Preferred Language

Client Info

Is the child in foster care?

Yes

No

Name of Client *

Date of birth

Race/ Ethnicity

Gender

Religious Affiliation

Preferred Language

Current Residence *

Current Legal Guardian

Synopsis of Relevant History

Strengths/ Hobbies/ Interests

Presenting Issues

Preliminary Goals of Service

People Places’ mentoring program is designed to offer support for children and youth impacted by adverse childhood experiences. A primary means of providing this support is through establishing positive, trusting, and enduring relationships with safe, understanding, and reliable adults.

Enhancing Coping Skills

Anger

Anxiety

Depression

Other (write in)Other (write in)

Enhance Social Competencies

Interpersonal Relationships

Planning and Decision Making

Peaceful Conflict Resolution

Other (write in)Other (write in)

Enhance Positive Identity

Self Esteem

Motivation/ Sense of Purpose

Family Relationships

Other (write in)Other (write in)

Any Other Goals

Additional Information

Additional Comments

Anti-SPAM Tool

Youth Mentoring Referral Form

Contact Info

Client’s Current Parents/ Caretakers

Client Info

Preliminary Goals of Service

Additional Information

Additional Comments

Statement on Systemic Inequality