1 Initial Mentor Request

District *

School Name *

Name of counselor referring *

Counselor Email *

School Phone Number *

Area Code Phone Number

Please explain why you feel a mentor would be beneficial to this student: *

School Student Number *

Student First Name and Last Initial *

Grade level *

If male, does the child require a male mentor?

YES NO

Is this student on an IEP? *

YES NO

Does this student have a 504 plan? *

YES NO

Check those behaviors or attitudes that you believe the student could USE SOME ASSISTANCE WITH:

Social Competence

Responsiveness Ability to adapt to and get along with different cultures Empathy Caring Communication skills Sense of humor Friendship skills

Problem-Solving

Planning Help-seeking Creative thinking Critical thinking Reducing impulsivity Making good choices

Autonomy

Sense of knowing and accepting who they are Self-efficacy or self-esteem Self-awareness Staying on task and task mastery Resisting negative peer or external pressure

Sense of Purpose and belief in a bright future

Goal setting Educational aspirations Optimism Faith Spiritual connectedness

With what academic behaviors might this student be having challenges?

Attendance Completing Homework Study Skills Organizational Skills

Check those behaviors or attitudes that you believe the student has as STRENGTHS:

Social Competence

Responsiveness Ability to adapt to and get along with different cultures Empathy Caring Communication skills Sense of humor Friendship skills

Problem-Solving

Planning Help-seeking Creative thinking Critical thinking Reducing impulsivity Making good choices

Autonomy

Sense of knowing and accepting who they are Self-efficacy or self-esteem Self-awareness Staying on task and task mastery Resisting negative peer or external pressure

Sense of Purpose and belief in a bright future

Goal setting Educational aspirations Optimism Faith Spiritual connectedness

What specific interests/strengths have you observed in this child? *

Enter the message as it's shown *

Date

Date Hour Minutes AM/PM Option

MENTOR REQUEST