/ Forms / By Partners School Based Referral Form Please utilize this form to refer a youth to our School-Based Mentoring programs. We are currently accepting referrals from: Poudre School District Thompson School District Weld County District 6 Estes Park School District Referring PersonReferring Person(Required) Name Title Referring Person's Email(Required) Referring Person's Phone(Required)Youth InformationYouth Name(Required) First Last Gender(Required)Age(Required)Age7891011121314151617Date of Birth(Required) MM slash DD slash YYYY Ethnicity(Required)School District(Required)Select School DistrictPoudre School DistrictThompson School DistrictWeld County School DistrictEstes Park School DistrictSchool (where the student will attend while in the program)(Required)Select SchoolBennett Elementary School-PSDBill Reid Middle School-TSDBlevins Middle School-PSDBoltz Middle School-PSDCottonwood Plains Elementary School-TSDCoyote Ridge Elementary School-TSDEdmondson Elementary School-TSDEstes Park Elementary School- EPEstes Park Middle School- EPEstes Park High School- EPHeath Middle School-WeldLesher Middle School-PSDLincoln Middle School-PSDLopez Elementary School-PSDMadison Elementary School- WeldOlander Elementary School-PSDPeak View Academy-TSDPolaris (K-12)-PSDRock Mountain High School-PSDThompson Valley High School - TSDTointon Academy-WeldWebber Middle School-PSDWinograd K-8 - WeldOtherIf you selected other, please list school below:Grade Level (for the year the student will be in the program)(Required)Integrated Services(Required)Yes, No, or UnknownYesNoUnknownThis field is hidden when viewing the formIf you selected yes and want to explain further (optional):Guardian InformationThere is an option to list more than one guardian and their information, however, it is not required. Guardian 1 Name(Required) First Last Relationship to Youth:(Required)Select RelationshipMotherFatherGrandparentStep-ParentSiblingUncle/AuntOtherEmail(Required) Phone(Required)Physical Address(Required) Street Address City State / Province / Region ZIP / Postal Code Guardian 2 Name First Last Relationship to Youth:Select RelationshipMotherFatherGrandparentStep-ParentOtherEmail PhonePhysical Address Street Address City State / Province / Region ZIP / Postal Code If multiple guardians are listed, who is the primary guardian contact?Youth DemographicsPlease fill out this section completely. Please check all statuses that apply to the youth(Required) McKinney-Vento Highly Mobile Free/Reduced Lunch Foster Care Kinship Care Migrant Family None of the above Known Risk Factors: Include both past and present. Check all that apply:(Required)As a reminder, a youth MUST have at least one risk factor to qualify for our programs. Academic Struggles Physical Abuse Sexual Abuse Domestic Violence Neglect Emotional/Verbal Abuse Parents separated/divorced Low income Poverty ESL Victim of Bullying Disability (not including ADD/ADHD) Youth Mental Health Concerns (including ADD/ADHD) Family Member Mental Health Concerns (including ADD/ADHD) Youth Legal Issues Family Member Legal Issues Youth ATOD Use Family ATOD Use Out of Home Placement Homeless Gang Affiliation Delinquent Behavior Parent/Sibling Incarceration Parent/Sibling Suicide/Death None of the above 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 None of the above Is there any other information that would be helpful for their 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 School-Based Mentoring program. I have also sent the parent/guardian the HelloSign link in an attempt to receive this permission in writingWho Gave PermissionDate Permission was Given MM slash DD slash YYYY
