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Mentee Referral-Kinship Mentoring

Referring Agency Information

1. Date of Referral (MM/DD/YYYY): *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Contact Person: *This question is required.

3. Referring Agency and Address: *This question is required.

4. Agency phone number: *This question is required.

5. Email: *This question is required. This question requires a valid email address.

6. Child's Name: *This question is required.

7. Date of Birth (MM/DD/YYYY): *This question is required. This question requires a valid date format of MM/DD/YYYY.

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8. Grade: *This question is required.

9. Name of Parents/Guardian: *This question is required.

10. Address: *This question is required.

11. Phone number: *This question is required.

12. Cell number:

13. Is the parent/guardian aware of the referral to Kinship Mentoring of Columbia County? *This question is required.

14. Name of School and Address: *This question is required.

15. Phone: *This question is required.

16. Kinship Mentoring is a voluntary youth mentoring program that focuses on quality time vs. material items and expensive experiences. Is the child/youth interested in forming a new, trusting relationship with an adult and participating in various activities? *This question is required.

17. What are their strengths and interests? *This question is required.

18. What services do they receive? *This question is required.

Please enter an 'other' value for this selection.

19. What are the youth's challenges or struggles? *This question is required.

20. What clubs or organizations are they involved in or interested in?

21. Have they experienced or been exposed to any of the following? *This question is required.

Emotional, physical, and sexual abuse
Substance use
Incarcerated Parent
Disability
Mental health
Single Parent Home
Poverty
Raised by a family member (non-parent)
Academic Challenges/School Attendance Challenges
Other - Write In Please enter an 'other' value for this selection.

22. How would you rate the youth's self-esteem? *This question is required.

VERY GOOD
GOOD
FAIR
POOR
Unsure

23. How do you think a mentor would benefit the child? *This question is required.

24. What type of person would you suggest we match with the child? *This question is required.