Mentee Referral

Mentee Referral

Please fill out the form in one sitting, as progress may not save. Click 'SUBMIT' at the bottom when you are done.
Youth's Name*

First NameLast Name
Date*

MonthDayYear
Date
Age*
Grade
School Attending (please include Zip code)
Parent/Guardian's name

First NameLast Name
Parent/Guardian Phone number*
Zip Code of Youth's Home
Does Parent/Guardian speak English? We have Spanish-speaking staff and translation services for other languages, if needed)

YesSome but not fluentNo
Does the referred youth speak English?

YesSome but not fluentNo
Referral/Your Name*

First NameLast Name
Referral Phone Number*
Referral Email*
Referral Agency/Organization
Since our volunteers are not trained mental health professionals we are UNABLE to serve the following:
- Youth who are struggling with drug/alcohol addiction requiring professional addiction counseling
- Youth who are active in gang activity and do not request help from a mentor
- Youth who have severe mental health/behavioral issues
- Youth who can't meet with a mentor regularly due to homelessness, running away, or other reasons
What prompted you to make this referral? How do you think this individual would benefit from a mentoring relationship?*
Please check and give a short explanation of the risk factors you think apply to the referred youth.
Single-parent home
Failing in school or lacks interest
Family member is incarcerated
Deceased parent
History of abuse/domestice violence
Unstable living situation
Social services involvement
Drug or alcohol abuse in family
Unstable/conflicted family relationships
Lacks appropriate social skills
Struggles with self-esteem
Exposed to negative influences
At-risk for teen pregnancy
At-risk for gang involvement
Family unable to interface with school
Lacks an adult advocate
Is a teen parent
Please let us know if you have done any of the following (it's ok if not):
If you are confident that the child and parents/guardians understand mentoring adequately and desire a SOY mentor, please have them complete and submit a Mentee Application. Click or share these links:

English: https://form.jotform.com/SOYFormsCentral/general-mentee-application

Spanish: https://form.jotform.com/SOYFormsCentral/spanish-mentee-application
Should be Empty: