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.).
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.
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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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.
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.
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.
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.
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
Neglect
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.
Browse Files
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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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