Please complete the information below and we will be in contact with you.

Youth Mentoring Referral Form

FAPT Funded Child

Is the child in foster care?

Maximum file size: 516MB

Contact Info

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

Client’s Current Caretaker(s)

Caretaker(s)

if different than above

Reason(s) for Referral

Please check any the apply to the youth (within the last year)

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
Enhance Social Competencies
Enhance Positive Identity
Independent Living

Additional Information

Please check any the apply to the youth (within the last year)

Maximum file size: 516MB

Additional Comments