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Student Referral Form
Paper City Mentoring Project
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* Indicates required question
Student Name
*
Your answer
Student Birthday
*
MM
/
DD
/
YYYY
School
*
Your answer
Grade
*
Your answer
Gender
*
Your answer
Parent Name and Email/phone
*
Your answer
Why would this student benefit from working with a mentor?
*
academic performance
social skills
self esteem
trauma support
Other:
Required
This question is for documentation of the mentee's progress and is required for assessment of the effectiveness of our program: Rate your perception of the student's overall well-being.
*
Choose
1 Well-being seems very low; student is desperate for intervention and guidance.
2
3
4
5
6
7
8
9
10 Well-being seems very high; student is succeeding to his/her highest potential.
What interests does the teen have?
*
Your answer
Have you spoken to the teen about having a mentor?
*
No
Yes, and they seem interested.
Yes, and they seem hesitant.
Person Making Referral and Email/phone
*
Your answer
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