B2H Mentee Referral Form

B2H Mentee Referral Form

Use this form to refer a system impacted youth age 15-21 to HOPE 585's mentorship program. This program is AT LEAST a year commitment and youth must be aware that they are being referred. Once completed, HOPE 585 staff will be in contact with next steps.
Background Information
Name of referee *

First NameLast Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Office Phone Number, if applicable
Please enter a valid phone number.
Organization Affiliation*

Monroe County Department of Human ServicesMonroe County Foster HomeMonroe County Group HomeMonroe County Juvenile Detention CenterPersonalOther
Relationship to Youth*

Case worker / managerFoster Home CoordinatorParent / GuardianTeacher / CounselorTherapistOther
Approximately how long have you known the youth? *
Youth Information
Name*

First NameLast Name
Youth's Date of Birth *

MonthDayYear
Date
Youth's Age *
Youth's Phone Number*
Please enter a valid phone number.
Youth's Current Residence Type*

Apartment / HouseFoster HomeGroup HomeShelterJuvenile DetentionRespite CareOther
Youth's Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current school, if applicable
Does the youth have a history of running away / AWOL*

YesNo
When was the last time he/she went AWOL?

MonthDayYear
Date
Please select all that apply to the youth:*

ADHDDepressionDiabetesSexual TraumaSexual AggressionAutismEating DisorderBipolar DisorderObsessive Compulsive DisorderPTSDIEPTrauma DisorderNot ApplicableOther
Please upload any documents pertaining to any of the above diagnosis.

Cancelof

Emergency Contact Information
Emergency Contact #1 *

First NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number *
Please enter a valid phone number.
Relationship to Youth*

MotherFatherSiblingCaseworkerAuntUncleGrandparentOther
Emergency Contact #2

First NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Youth

MotherFatherSiblingCaseworkerAuntUncleGrandparentOther

Questionnaire

Please answer each question thoroughly and honestly, as it will help to pair a youth with the best mentor.
Does the youth have history of any of the following (select all that apply)?*

NeglectPhysical AbuseVerbal AbuseSexual MisconductOther
In your opinion, how will the youth benefit from the B2H mentoring program (your main reasons for referring youth)? *
In your opinion, what are the youth's strengths? *
In your opinion, what are the youth's weaknesses? *
Have the biological parents' rights been terminated?*

YesNo
If parental rights exist, how often does the youth have contact with their parents?*

Not at allDailyWeeklyMonthlyYearly
Does the youth have siblings?*

YesNo
Has the youth had previous mentors with any person / organization?*

YesNoInformally
Please list the name of the agency and/or mentor?
Do we have permission to contact both mentor and/or agency?

YesNo
Please select all characteristics of a mentor that would be best fit for this youth?*

MaleFemaleYoungerOlderAthleticComicalPatientSpontaneousFree - SpiritedEthnic PreferencesLGBTQ+Other
Please include any additional information that would be beneficial to the youth's acceptance. *
Please select mentee adult T - Shirt size.*

XS - SMLXLXXL1X - 3XOther
Referring Date

MonthDayYear
Date
Signature of Referee

Clear
Should be Empty: