B2H Mentee Referral
Hope 585's, Bridge to Hope Mentorship Program, provides Monroe County system impacted youth ages 15-21, with hope centered, long- lasting, mentorship relationships. Through Hope Rising Friday Nights, youth are led through a curriculum that will equip them with skills needed for adulthood and provide a sense of both hope and belonging. Please note, youth MUST be system - impacted, within the appropriate age range, consistently attending school and willing to participate fully in program and have access to proper communication resources (i.e., cellphone, email, etc.).
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Referrer Background Information
Referrer's Name
*
First Name
Last Name
Referrer's Email
*
example@example.com
Referrer's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Affiliation
*
Please Select
Monroe County FACT
Monroe County CPS
Hillside
HOPE 585
RCSD
Villa of Hope
Encompass / Lighthouse
Monroe County Foster Home
Other
Relationship to Youth
*
Parent / Guardian
Case Worker / Manager
Teacher / Counselor
Family Navigator
Other
Approximately, how long have you known the youth?
*
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Youth Eligibility
Is the youth impacted by any involuntary systems
*
Yes
No
Which systems are the youth impacted by?
*
Foster Care
Juvenile Justice
Incarceration
Monroe County PIC Team
Child Welfare
Social Services
Hillside
Monroe County FACT Team
Villa of Hope
Experiencing Homelessness
Other
Age of youth
*
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Mentee Demographics
Please fill out all information accurately and honestly.
Mentee Name
*
First Name
Last Name
Mentee's Age
*
Mentee's DOB
*
-
Month
-
Day
Year
Date
Mentee's Current School
*
Mentee's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mentee's Email (optional)
example@example.com
Mentee's Current Residence Type
*
Please Select
Foster Home
Apartment
House
Duplex
Independent Living
Other
Mentee's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select mentee adult T-Shirt size
*
XS/S
M
L
XL
Other
Parent / Guardian
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (optional)
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact
Same as Parent/Guardian
*
Yes
No
Emergency Contact #1
First Name
Last Name
Relationship to mentee
Please Select
Relative
Caseworker / Case Manager
Family Friend
Teacher
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #2
First Name
Last Name
Relationship to mentee
Please Select
Relative
Caseworker / Case Manager
Family Friend
Teacher
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Referral Questionnaire
Please answer all questions thoroughly, accurately and honestly.
Does the mentee have history of any of the following (select all that apply)
*
Neglect
Physical Abuse
Sexual Abuse
Mental Abuse
Homelessness
Sexual Harassment / Misconduct
Poverty
Foster Care
Other
Have the biological parents rights been terminated?
*
Yes
No
Other
If parental rights exist, how often does the mentee have contact?
*
Daily
Weekly
Monthly
Other
Does the mentee have siblings?
*
Yes
No
Does the mentee have a history of running away / AWOL?
*
Yes
No
Somewhat
When was the last known date mentee went AWOL?
-
Month
-
Day
Year
Date
Has the mentee been diagnosed with any of the following (select all that apply)?
*
ADHD
Depression
Anxiety
Bi-Polar Disorder
OCD
Schizophrenia
PTSD
Eating Disorder
IEP
Autism
Sexual Trauma
Sexual Misconduct
Other
Please upload any documents proving and/or pertaining to any of the above diagnosis.
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Referral Questionnaire
Please answer all questions thoroughly, accurately and honestly.
Does the mentee have history of any of the following (please select all that apply)?
*
Diabetes
Obesity
Asthma
Sickle Cell
Leukemia
Cancer
Substance Abuse
Lice
Chicken Pox
Other
Does mentee have any allergies?
*
Yes
No
If yes, please list all below.
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Referral Questionnaire
Please answer all questions thoroughly, accurately and honestly.
In your opinion, how would the youth benefit from the B2H mentorship program (main reasons for referring)?
*
In your opinion, what are the youth's strengths?
*
In your opinion, what are the youth's weaknesses?
*
Please select all characteristics of a mentor that would be best fit for the youth.
*
Female
Male
Older
Younger
LGBTQ+
Athletic
Comical
Patient
Spontaneous
Ethnic Preferences
Free - Spirited
Artistic
Outgoing
Reserved
Please include any additional information that would be beneficial to the youth's acceptance.
Signature
*
Submit
Submit
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