1 Initial Mentor Request (this has that form Donna always needs)

MENTOR REQUEST
Counselor's Email (so you receive confirmation)
example@example.com
District
School Name
Name of counselor referring
School Phone Number
Format: (000) 000-0000.
Please explain why you feel a mentor would be beneficial to this student:
School Student Number
Student First Name and Last Initial
Grade level
If male, does the child require a male mentor?
Is this student on an IEP?
Does this student have a 504 plan?
Check those behaviors or attitudes that you believe the student could USE SOME ASSISTANCE WITH:
Social Competence
Problem-Solving
Autonomy
Sense of Purpose and belief in a bright future
With what academic behaviors might this student be having challenges?
Check those behaviors or attitudes that you believe the student has as STRENGTHS:
Social Competence
Problem-Solving
Autonomy
Sense of Purpose and belief in a bright future
What specific interests/strengths have you observed in this child?
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Date

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty: