BBRB

* Mentee's First Name

* Mentee's Last Name

Mentee's Telephone (optional)

Mentee's Email (optional)

Mentee's Date of Birth

* Parent's First Name

* Parent's Last Name

Address

City

State

Zipcode

* Parent's Telephone

* Parent's Email

Best time to contact

From: : To: :

Preferred method of communication?
Telephone Text Email

Mentee's School

Mentee's Grade

Is mentee the only child?
Yes No

If mentee has sibling please select answer that applies.
Mentee has 1 sibling Mentee has 2 siblings Mentee has 3 or more siblings

Is mentee being raised in one parent home or both parents?
One Parent Both Parents

Does Mentee have an IEP?
Yes No

Does Mentee have any mental health diagnosis?
Yes No

How would you rate mentees level of self esteem on a scale of 1 to 10?

How would you rate mentees verbal communication skills on a scale of 1 to 10?

How would you rate mentees ability to regulate their emotions on a scale of 1 to 10?

How would you rate mentees ability to make friend within his social networks on a scale of 1 to 10?

How often is mentee attending school?

Always unless theres an emergency or unforeseen circumstance

Not often

Struggling with regular school attendance

Is Mentee able to read and comprehend at the expected for his grade level?
Yes No Not Sure

Are you experiencing any behavioral problems with mentee currently or in the past?

Is Mentee connected to any mental health providers?

Does Mentee have medical insurance?
Yes No

Insurance provider for mentee:

Is mentee able to commit to meeting with a program mentor once a week for 1 hour?
Yes No

Will mentees availability to meet with mentors remain the same or change from week to week?

Yes - their schedule will be remain the same

No - Mentee will require a flexible schedule

Times for selected days:

Does mentee have their own cell phone or laptop that can be used for meetings with mentor?

Yes - Mentee has access to a devise required for mentoring

No - Mentee does not have access to devise but is interesting in mentoring

Mentee’s Strengths?

Mentee's Challenges?

Mentee's Hobbies?

Mentee's extracurricular activity?

How does mentee like to spend his free time?

How much time does mentee spend on the internet/social media?

Please describe how mentee displays resilience.

Is mentee comfortable advocating for himself?
Yes No

How do you hope this mentoring program benefits mentees? Please explain.

Yes No

Mentors are required to speak with mentees parents at least once a month, are you willing to schedule time to speak with mentor for a minimum of 15 mins once a month?
Yes No

Will you feel comfortable reporting issues with mentorship with program staff?
Yes No

Mentee Form (* Required fields)