Student Referral Form
Program Disclaimer
The mentoring program is available to male students ages 10-18 only.
Information that is considered sensitive should not be shared electronically. Please avoid including confidential details such as medical records, diagnoses, or protected student information when submitting this form. Additional information can be shared through secure channels if needed.
Please note that all counseling information is confidential unless:
Confidentiality Exceptions
Harm to self
Harm to others
Someone is harming the student
Disclosure is required by subpoena
The student provides permission to share
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Student Information
Student Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Grade Level:
School Name:
Student Address:
Student Phone (if applicable):
Format: (000) 000-0000.
Parent / Guardian Information
Parent/Guardian Name(s):
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Preferred Method of Contact:
Phone
Email
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Referring School Information
Staff Name:
Position/Role:
(Example: Teacher, Counselor, Principal, Social Worker, etc.)
School Name:
Contact Email:
example@example.com
Contact Phone:
Format: (000) 000-0000.
Reason for Referral (Check all that apply)
Academic Support
Behavior / Discipline Concerns
Social / Emotional Support
Leadership Development
Mentorship / Positive Role Models
Attendance Issues
College & Career Readiness
Other:
Other
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Student Strengths
(What does the student do well?)
Areas of Concern
(Please describe any challenges or areas where support is needed)
Additional Notes
Consent & Acknowledgment
I confirm that this referral is being submitted to support the student's growth and development. I understand that parent/guardian consent will be required for participation.
Referring Staff Signature:
Date:
-
Month
-
Day
Year
Date
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