/ 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, InstagramThis field is for validation purposes and should be left unchanged.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 ID Number(Required)School (where the student will attend while in the program)(Required)Select SchoolBauder Elementary School-PSDBennett Elementary School-PSDBill Reed Middle School-TSDBlevins Middle School-PSDBoltz Middle School-PSDCottonwood Plains Elementary School-TSDCoyote Ridge Elementary School-TSDDos Rios Elementary School-WeldEdmondson Elementary School-TSDEstes Park Elementary School- EPEstes Park Middle School- EPEstes Park High School- EPFranklin Middle School-WeldHeath Middle School-WeldLaurel Elementary School-PSDLesher Middle School-PSDLincoln Middle School-PSDLopez Elementary School-PSDLucile Erwin Middle School-TSDMadison Elementary School- WeldOlander Elementary School-PSDPeak View Academy-TSDPolaris (K-12)-PSDRocky 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 (when 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 Guardian 1 Relationship to Youth:(Required)Select RelationshipMotherFatherGrandparentStep-ParentSiblingUncle/AuntOtherGuardian 1 Email(Required) Guardian 1 Phone(Required)Guardian 1 Physical Address(Required) Street Address City State / Province / Region ZIP / Postal Code Guardian 2 Name First Last Guardian 2 Relationship to Youth:Select RelationshipMotherFatherGrandparentStep-ParentOtherGuardian 2 Email Guardian 2 PhoneGuardian 2 Physical Address (Optional) Street Address City State / Province / Region ZIP / Postal Code If multiple guardians are listed, who is the primary guardian contact?(Required)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) 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 As a reminder, a youth MUST have at least one risk factor to qualify for our programs. 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 Please explain any of the selected choices if applicable:Recommendations For MatchingWhat are the youth's greatest strengths?(Required)What kind of support are you hoping this youth would receive from having a mentor?(Required)What kind of person would work best with this youth?(Required)Is there any other information that would be helpful for us or 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 School-Based Mentoring program. I have also sent the parent/guardian the DropBox Sign link in an attempt to receive this permission in writing.Who Gave Permission(Required)Date Permission was Given(Required) MM slash DD slash YYYY CAPTCHA
