Mentee Referral Form – Part A
To be completed by agency representative. Your referral will only be seen by Trusted Mentors Staff. It is the Case Manager's responsibility to have the mentee complete Part B either electronically or on paper. If you have questions, please reach out to the Trusted Mentors staff at info@trustedmentors.org. Thanks!
Referral Date
-
Month
-
Day
Year
Date
MENTEE Name
*
Mentee First Name
Mentee Last Name
MENTEE Phone Number
*
( so we can reach out if Part B is delayed)
Format: (000) 000-0000.
MENTEE Email
example@example.com
Referring Agency Representative
*
(Your Name)
Referring Agency
*
Phone for Agency Representative
Format: (000) 000-0000.
Email for Representative
*
example@example.com
Is the Agency St. Vincent dePaul - Changing Lives Forever?
*
Yes
No
Indicate the CLF Parish:
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Agency Representative Input
Date of Admittance into your program:
-
Month
-
Day
Year
Date
Please explain the referral’s participation in your program.
Why would this person benefit from a mentor?
Ask the mentee, how do they rate their level of:
Rows
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
Self-esteem
Social Skills
Family Support
Communication Skills
Peer Relation
Motivation for Change
What is some useful information that we should know about this person? (triggers, interested topics, personality, strengths, etc) Think about anything that could help us make a positive match with a mentor.
What specific areas does this mentee need assistance?
Personal finance (e.g. budgeting from paycheck to paycheck)
Obtaining employment or improving employment
Improving level of education
Improving homemaking skills
Establishing a network of reliable people
Childcare and parenting skills
Maintaining stable housing
Transitioning from recovery house into life
Transition from incarceration to the community
Transition from foster care to independent life
Completing the process of divorce
Helping to develop methods to prevent living in crisis
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Background
Is the referral is in the criminal justice system?
*
Yes
No
Unknown
Marion County issued gallery #
DOC (IN Dept of Corrections) #
History of convictions:
0/0255
Sex Offense?
Yes
No
To assist in a successful mentor matching process, does the referral have a history of:
Addiction
Mental Illness
Domestic Violence
Please describe the current situation.
0/0255
To assist with matching, does the referral have a confirmed, diagnosed mental or physical disability?
Yes
No
Unknown
Please provide an explanation including the diagnosis, current treatment and degree of stability.
0/0255
To assist with matching, are there legal conditions that might affect where the mentor/mentee can meet?
*
None
Work Release
Parole
Restraining Order
Other
Please provide an explanation of the legal conditions.
0/0255
Work Release Out Date:
What county will they live in, post release?
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Mentee Readiness
Completed release form, if required?
*
Yes
Not Required
Please attach release form here or email to jenglert@trustedmentors.org
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Cancel
of
Does the prospective mentee meet the recommended minimum for mentee readiness?
*
Rows
Yes
No
N/A
Desires a self-sufficient and stable lifestyle?
Understands and desires a volunteer mentor?
Able to commit to and maintain a mentor/mentee relationship?
Minimum of 30 days clean and sober?
Conscientiously participating in a recovery program if diagnosed with an addiction?
ADDITIONAL COMMENTS
0/0255
The mentee has voluntarily requested a mentor. A mentor is not a requirement of our program.
*
Signature
Submit
Should be Empty: