Intake & Assessment FormReady, set, grow! Fill out some info and we will be in touch shortly! We can't wait to hear from you! Meetee Information Name * First Name Last Name Gender * Male Female Other Date of Birth * MM DD YYYY Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Enter N/A if youth does not have an email. Is the Mentee currently attending school? * Yes No Current School Grade 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Post Graduate Not Applicable Languages Spoken * Family's Cultural Background * Does the mentee need an interpreter? * Option 1 Option 2 Which best applies to the mentee? * Citizen Permanent Resident Refugee Other Is the mentee on any medication that we need to be aware of? * Yes No If yes, please describe: Any Allergies? * Yes No If yes, please describe: Does the mentee have any emotional, mental, physical, or specific medical health conditions that we should know about? * Yes No If yes, please describe: Is the youth or family currently involved with the Child Welfare Services (CWA)? * Yes No What is the level of Involvement? Family Enhancement Protection None of the above CWA Office Location Phone (###) ### #### Social Worker's Name Emergency Contact Information Contact Name * First Name Last Name Relationship * Phone * (###) ### #### Parent/Guardian Information Parent/Guardian's Contact Name * First Name Last Name Relationship to Mentee * Phone * (###) ### #### Email * Parent languages spoken * Does parents need an interpreter? * Yes No Other Parent/Guardian(s) Name(s) if any: Enter N/A if not applicable Relationship to Mentee Enter N/A if not applicable Contact Phone: Enter N/A if not applicable Getting to Know the Mentee This information will help us with matching the mentee with a compatible mentor. Why does the mentee want/need a mentor? * Tell us about the mentee's personality and strengths. * What would you say are some of the mentees challenges? * Is there anything you would like us to be aware of that would assist us in finding the right mentor for the mentee? * Yes No If yes, please describe: List some of the goals/changes the mentee would like to achieve while in the program. This could either be academic, social, and personal skills, cultural connection, professional development, networking, communication skills, leadership skills, spiritual development, or other skills. * How did you hear about this program? * InsideOut Mentors Website Social Media Email Newsletter Word of mouth School District Local Church Other Referral (To be completed by referring agencies only) Referring Agency Referred by (name): Phone (###) ### #### Email Thank you! We look forward to working with you and will contact you soon. Congratulations on making the first ste in personal growth. We can’t wait to mee you!
