S.T.A.N.D Transformative Mentoring Program Referral

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Mission Statement

The S.T.A.N.D. (Sustainable Transformation Allowing New Direction) Power Group Alternatives Credible Messenger Mentoring's mission is to establish healthy, trusting, life-changing relationships, through a culturally relevant, father-focused healing-centered transformational process, offered to youth and young adults, ages 14 to 24, who have been or who are at risk of being impacted by gang culture, violence, and recruitment, by providing power group prevention and intervention programs and services, as well as, sustainable resource support.

Program Objectives

S.T.A.N.D utilizes lived experience and evidence-based practices to deliver intervention and prevention support services that eliminate barriers and unlearn behaviors that can lead to power group involvement.
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Please email to Lsykes@innercityactionnetwork.org with subject in caps
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Date of Birth* This field is required.
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Month
Day
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Age* This field is required.
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Home Phone
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Cell Phone* This field is required.
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Email* This field is required.
example@example.com
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Who does the participant live with?* This field is required.
Boy/Girlfriend
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Grade* This field is required.
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Student ID#
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Enrolled* This field is required.
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GED Program
Is the participant currently enrolled?
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Diversion
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Are you currently receiving other services, please list the agency name and specify the type of service (e.g., case management, mentoring, etc:
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Is the participant involved in any activities?
Participant is currently receiving other services, please list agency name and specify type of service e.g., case management, mentoring, etc:
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Is the participant involved in any activities?* This field is required.
Sports
Leadership
Job
Arts
Music
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Parenting
Sibling Care
Other Activity:
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How does the participant identify Race/Ethnicity: (select all that apply and specify if necessary)* This field is required.
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Name* This field is required.
First Name
Last Name
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Relationship to participant* This field is required.
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Contact Phone* This field is required.
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Alternative Phone
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Email* This field is required.
example@example.com
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Does parent know you are making a referral?
Yes
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Do not notify parent
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Does parent need an intrepreter?
Yes
No
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If yes, what language?
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Does participant know you are making this referral?YesNo
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Yes
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Is participant willing to participate?
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Name
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Phone
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Email
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Administrative Section -Do Not Write In This Section-
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Assigned Contact Support
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Phone Contact
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Email
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Page 1 of 2 Implemented October, 2020
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Is your young person interested in Job Expereince, Appreticeshiops/ Internships, Job Preparedness, Income and Independance.
Work Domain
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Is your young person interested in Communication Skills, Conflict Resolution, Family Unification, Intimacy and Support aka What LOVE Looks LIke.
Relationships Domain
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Is your young person interested in Physical Activity, Diet and Nutrition, Behavioral Health, LIfestyle and Sexuality.
Health Domain
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Is your young person interested in Diploma, GED or College, Literacy, Credentials, Learnign Skills, Carer Planning.
Education Domain
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Is your young person interested in Civic Engagement, Community Leadership, Service to Others, Responsibility.
Community Domain
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Is your young person interested in Personal Expression, Visual Arts, Performing Arts, Language Arts/ Music
Creativity Domain
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Brief Statement of Participants's Current Circumstance * This field is required.
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Participant's Strengths * This field is required.
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