/ Forms / By Partners Community Based Referral Form Please utilize this form to refer a youth to our community-based programs. Referring PersonReferring Person(Required) Name Title Referring Agency Email(Required) Phone(Required)Youth InformationPlease fill out this section completely.Name(Required) First Last Gender(Required) Age(Required)7891011121314151617Date of Birth(Required) MM slash DD slash YYYY Ethnicity(Required) Name(s) of Parent(s)/Guardian(s) living in the home:(Required) Add RemoveAdd multiple names by clicking the plus sign. (If not applicable type N/A)Name(s) of Parent(s)/Guardian(s) living outside of the home:(Required) Add RemoveAdd multiple names by clicking the plus sign. (If not applicable type N/A)Phone(Required)Email (if known) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Language Spoken in the Home(Required) Siblings and significant others in the home (please include ages of each):(Required) Add RemoveAdd multiple names by clicking the plus sign. (If not applicable type N/A)Relationship to youth(Required) Add RemoveAdd multiple names by clicking the plus sign. (If not applicable type N/A)Please describe the youth's behavior at home, if known:Youth's attitude towards self:(Required) Very Good Good Fair Poor School InformationPlease fill out completely. School Name:(Required) Grade Level (Current - if summer, use INCOMING grade)(Required) Student ID Number Integrated Services(Required)YesNoUnknownHiddenIf you selected yes and want to explain further (optional): School Counselor/ Social Worker/ Other PhoneYouth DemographicsPlease fill out this section completely. Known Risk Factors: Youth (please include both past and present):(Required)As a reminder, a youth MUST have at least one risk factor to qualify for our programs. Constant Relocation Delinquency (not legally involved) Disability (physical, learning, mental, etc. --NOT including ADD/ADHD) Domestic Violence Emotional/Verbal Abuse English as Second Language Gang Affiliation Homelessness Substance Abuse/Dependency Legal Issues Low Income Mental Health Concerns (including ADD/ADHD) Out of Home Placement Neglect Incarceration Parent/Sibling Suicide/Death Physical Abuse Poverty Sexual Abuse Suicide Attempts Victim of Bullying Please explain any of the selected choices if applicable:Known Risk Factors: Family (please include both past and present):(Required) Constant Relocation Delinquency (not legally involved) Disability (physical, learning, mental, etc. --NOT including ADD/ADHD) Domestic Violence Emotional/Verbal Abuse English as Second Language Gang Affiliation Homelessness Substance Abuse/Dependency Legal Issues Low Income Mental Health Concerns (including ADD/ADHD) Out of Home Placement Neglect Incarceration Parent/Sibling Suicide/Death Physical Abuse Poverty Sexual Abuse Suicide Attempts Victim of Bullying Please explain any of the selected choices if applicable:Youth Behavior in School: Issues or behavior patterns affecting the youth's school success. Check all that apply.(Required) Low Grades Learning Disability Poor Attendace Poor Peer Relations Agressive/Fighting Defiant of Authority Overly dependent of peers Overly dependent on adults Quiet/Withdrawn Experiments with drugs/alcohol Destructive Fearful/Anxious Disrupts Classroom Emotional Outbursts Recommendation for MatchingWhat are the youth's greatest strengths?(Required)What kind of person would work best with this youth?(Required)Is there any other information that would be helpful for a mentor to know?Consent(Required) I agree to the following:I have received verbal permission from the referred youth’s parent/guardian to release their academic, family, and social background to the Partners Community-Based Mentoring program. I have also sent the parent/guardian the HelloSign link in attempt to receive this permission in writingWho Gave Permission: Date Permission was given: MM slash DD slash YYYY