Mentee Referral Application

📞 650-368-4444 | 📧 mentor@friendsforyouth.org | 🌐 www.friendsforyouth.org

1-to-1 Mentee

First Name*

Last Name*

Date of Birth*

Mobile Phone*

Email*

T-Shirt Size*:


School Attending*

Grade Level*

Gender*


Sexual Orientation*:


Ethnicity*


Primary Language*:


Secondary Language*:


Medical Conditions*:


Medical Conditions Allergies (write NONE if this doesn't apply)*:

Medical Conditions Others (write NONE if this doesn't apply)*:

Select which categories apply*:


Other category if not listed above (write NONE if this doesn't apply)*:

Any other Challenges?*:

Notes on Challenges*:


Mentee From Home With A History Of*:


Counseling*:


Counseling Start Date*:

Counseling End Date*:

Address*:

City*:


City if not listed above option (write N/A if this doesn't apply)*:

State*:


Zip Code*:

Family Household Income*:


Household Size*:


Participates In Free/Reduced Lunch*:


Family Structure*:


Career Focused Interests*:


Career Focused Interests Other*:

Interests*:


Interests Other*:

Reason for Referral*:

Primary Emergency Contact*:

Primary Emergency Contact Mobile Phone*:

Primary Emergency Contact Email*:

Primary Emergency Contact Relationship*:


Name of Parent/ Guardian*

Relationship*


Living At Home?*:

Name of Parent/ Guardian*

Relationship*:


Living at home?*:

Siblings Names And Ages*:

Other Agencies Working with Youth/Family and Contact Info*:


If youth has legal history, please describe offense(s), date(s),
present status/probation terms and P.O contact info*:


Has the youth experienced any changes/stressors like(moves, deaths, births,
remarriage, separations/divorce, witness any accidents, trauma, domestic violence, etc.)?
Who does the youth primarily live with? Any specific custody/visitation arrangements if*


Why do you think this young person is ready for a mentor?*:

Referral Agency*

Referral Agent*

Referral Agent's Email*

Referral Agent's Phone Number*

Thank you for taking the time to fill out our Agency Referral form. The information you have
provided will greatly help us in matching this youth with an appropriate mentor.

I understand that information provided will be kept confidential and will be used in assisting
the Program Staff in finding an appropriate match. Incomplete forms will delay the application process.