Mentee Intake Form
Personal Information
Child's Name
*
First Name
Last Name
Parent / Guardian Name
*
First Name
Last Name
Street Address
City
State
Zip
Home phone
*
Work phone
Email
*
example@example.com
Age
*
Gender
*
School
*
Grade
*
Requested by:
*
This child is being referred for assistance in the following areas (check all that apply).
*
Academic Issues
Behavioral Issues
Deliquency
Self Esteem
Study Habits
Social Skills
Family Issues
Attitude
Depression
Turancy
Lack of Motivation
Other
Interest and Hobbies
*
Reading
Sports
Music
Visual Arts
Travel
Poetry
Electronic Games
Politics
What best describes you?
*
Outgoing
Funny
Intuitive
Reserved
Vibrant
Passionate
Extrovert
Introvert
Why do you feel this child might benefit from a Mentor?
With what specific academic subjects, if any does the child need assistance?
Additional Comments
Submit
Should be Empty: