Forms / By Partners School Based Referral Form Please utilize this form to refer a youth to our school based programs. Referring PersonReferring Person(Required) Name Title Email(Required) Phone(Required)Youth InformationName(Required) First Last Gender(Required) Age(Required)7891011121314151617Date of Birth(Required) MM slash DD slash YYYY Ethnicity(Required) School District(Required)Poudre School DistrictThompson School DistrictWeld County School DistrictEstes Park School DistrictSchool (2022-2023)(Required)Lopez Elementary School-PSDOlander Elementary School-PSDBlevins Middle School-PSDBoltz Middle School-PSDLincoln Middle School-PSDWebber Middle School-PSDRock Mountain High School-PSDCottonwood Plains Elementary School-TSDPolaris (K-12)-PSDCoyote Ridge Elementary School-TSDEdmondson Elementary School-TSDLincoln Elementary School-TSDMary Blair Elementary School-TSDWinona Elementary School-TSDBill Reid Middle School-TSDRiverview (K-8)- TSDWalt Clark Middle School- TSDLoveland High School-TSDMadison Elementary School- WeldBrentwood Middle School- WeldHeath Middle School-WeldJefferson Junior High School- WeldJefferson High School-WeldMeeker Elementary School- WeldEstes Park Elementary School- EPEstes Park Middle School- EPEstes Park High School- EPOtherIf you selected other, please list school below: Grade Level (2022-2023)(Required) Integrated Services(Required)YesNoUnknownHiddenIf 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(Required) First Last Relationship to Youth:(Required)MotherFatherGrandparentStep-ParentOtherEmail(Required) Phone(Required)Physical Address(Required) Street Address City State / Province / Region ZIP / Postal Code Guardian First Last Relationship to Youth:MotherFatherGrandparentStep-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 Permission Date Permission was Given MM slash DD slash YYYY