Mentee Referral Form

Mentee Referral Form
Young Persons Name
Age
Year
School
Requested by
Position
Phone Number

Area CodePhone Number
The child is being referred for assistance in the following areas (check all that apply)

Academic IssuesSelf-EsteemFamily IssuesBehavioral IssuesStudy HabitsSpecial NeedsCCE or CSESocial SkillsAttitudeVocational TrainingPeer RelationshipsOther
Why do you feel this YP might benefit from a mentor?
What particular interests, either in school or out, do you know of that the YP has?

On a scale of 1–10 (10 being highest) rate the student’s level of:

Rows	Rating
Academic Performance
Social Skills
Self-Esteem
Family Support
Communication Skills
Attitude about school/Education
Peer Relations