Cultivating Hope Mentoring Participant Application

Cultivating Hope Mentoring Application

Memory Lane Farm, Inc. 8640 Heritage Dr., Marshfield WI 54449
The following application is to be completed for Memory Lane Farm Cultivating Hope Mentoring participants. This form is designed to provide necessary information to our mentoring staff before our initial session in order to make the most productive and efficient use of our time together. All information provided is strictly confidential and will not be released without written consent.
GENERAL CONTACT INFORMATION
Today's Date:*

MonthDayYear
Date
Name of Participant to be Mentored:*
Nickname, if any:
Is applicant (person who will be mentored):*

AdultMinorOther
Current Age of Participant
Birthday:
If Participant is a minor, please list grade of child:
Current grade
Address:*
City*
State*
Email:*
example@example.com
Phone:*
Parent(s)/Guardian Legal Name (completing this application/main contact):
Emergency Contact Name:*
Emergency Phone:*

Area CodePhone Number
Relationship:*
Referral source name:
Who suggested this program to you?
Referral relationship (i.e. teacher, counselor, pastor, professional):
Child's Last Name:
Child's First Name:
Age of Child:
FAMILY INFORMATION

Please share the following information regarding the participant's family
How many immediate family members are in your household?
Please list names and ages of siblings and any other household members (living in the home):
Are there any other people in the participants life you think we should know about?
PARTICIPANT DESCRIPTION

This section will help us have a better understanding of how we may best serve the participant
Participant has a history of:

ADHDAutismAdoptionAngerAnxietyBullyingCommunity ViolenceConflictDepressionDomestic ViolenceEmotional AbuseFamily DivorceFamily SeparationFoster CareFrequent RelocationGangsLabor TraffickingLearning/Cognitive/DisabilityLossMilitaryNeglectOCDODDParental DeathParental IncarcerationParental Substance AbusePersonal Substance AbusePhysical AbusePTSDSchool ViolenceSelf HarmSex TraffickingSexual AbuseSuicide AttemptsSuicide IdeationSuicide ThreatsTraumatic experienceTruancyVerbal AbuseOther
The participant currently struggles with:

ADHDAngerAnxietyConflictDepressionDestructive behaviorsEmpathyGriefLearning Disability(s)Low self esteemOCDODDPTSDRelationshipsSocial Skill ConcernsSchool performanceSelf HarmSelf Talk/Self WorthSensory ProcessingSuicidal Ideation/ThreatsSuicidal AttemptsOther
How long has the participant been struggling with these issues?
Please share anything you feel would be helpful in understanding the participant's situation
Does the participant have any known triggers we should be aware of?
PROGRAM INFORMATION

(completed by participant or parent/guardian)
Of those listed above, which one concern should be addressed in our program that can be resolved or worked on in our 12-week program?*
How can you, your child or family benefit from this program (be as specific as possible):*
Is participant currently under the care of Therapist/Psychologist?
Please list any current diagnoses:
Do you identify with a place of worship? If so, where?
Are there any other issues that you feel our leadership team should be made aware of (medical, allergies, emotional, behavioral, physical limitations, etc.)*
POTENTIAL AREAS OF DEVELOPMENT
Please identify the top five (5) outcomes you hope to see in the participant:

BoundariesComfortCommunicationConfidenceEmpathyImproved Participation in School/Home LifeImproved RelationshipsLeadershipListening SkillsRespect (self/others)ResponsibilitySelf ControlSelf EsteemSelf ExpressionSense of BelongingSense of PurposeSense of SafetySense of Value/WorthSocial SkillsTrustOther
Strength and Character traits (i.e. participant is very compassionate)
Is the particapant able to identify concerns, and ready to make to work toward making changes in life?

Yes!No, not at this timeOther
LIABILITY WAIVER
All participant application and personal information is considered confidential and only information critical to the success of the participant will be shared with Session Leaders or Mentors.

The staff and volunteers of Memory Lane Farm come with many years of combined mentoring, and life experience and desire to play an important and impactful role in the development of our participants.

Staff and volunteers of Memory Lane Farm, Inc. are not counselors, therapists or are authorized to offer any professional advice. We, however are happy to offer resources for families and participants.

I have read and understand the Participant and Parent/Guardian Guidelines as stated above:
Participant/ Parent/Guardian Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Cultivating Hope Mentoring Application

GENERAL CONTACT INFORMATION

FAMILY INFORMATION

PARTICIPANT DESCRIPTION

PROGRAM INFORMATION

POTENTIAL AREAS OF DEVELOPMENT

LIABILITY WAIVER