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*
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?

YESNO
Is this student on an IEP?*

YESNO
Does this student have a 504 plan?*

YESNO
Check those behaviors or attitudes that you believe the student could USE SOME ASSISTANCE WITH:
Social Competence

ResponsivenessAbility to adapt to and get along with different culturesEmpathyCaringCommunication skillsSense of humorFriendship skills
Problem-Solving

PlanningHelp-seekingCreative thinkingCritical thinkingReducing impulsivityMaking good choices
Autonomy

Sense of knowing and accepting who they areSelf-efficacy or self-esteemSelf-awarenessStaying on task and task masteryResisting negative peer or external pressure
Sense of Purpose and belief in a bright future

Goal settingEducational aspirationsOptimismFaithSpiritual connectedness
With what academic behaviors might this student be having challenges?

AttendanceCompleting HomeworkStudy SkillsOrganizational Skills
Check those behaviors or attitudes that you believe the student has as STRENGTHS:
Social Competence

ResponsivenessAbility to adapt to and get along with different culturesEmpathyCaringCommunication skillsSense of humorFriendship skills
Problem-Solving

PlanningHelp-seekingCreative thinkingCritical thinkingReducing impulsivityMaking good choices
Autonomy

Sense of knowing and accepting who they areSelf-efficacy or self-esteemSelf-awarenessStaying on task and task masteryResisting negative peer or external pressure
Sense of Purpose and belief in a bright future

Goal settingEducational aspirationsOptimismFaithSpiritual connectedness
What specific interests/strengths have you observed in this child?*
Enter the message as it's shown*
Date

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

MENTOR REQUEST