In-School Mentoring Referral Form About YouName(Required) First Last Your Title (e.g. School Support Counsellor)(Required) Add RemoveYour Phone NumberYour Email Address(Required) School Nutrition Break Time(s)(Required) About the studentIf the student is already matched with a Big in our Community-Based program, they are not eligible for an In-School mentoring match.(Required) First Name Gender Grade School Please share the reason for referral and how the student could benefit from having a mentor.(Required)Would the student be open to being matched with a mentor of a different gender? If yes, please specify (e.g. female preference)(Required) Describe the student's personality (please check any that best describe the student).(Required) Outgoing Passive Active Friendly Talkative Shy/Withdrawn Independent Helpful Quirky Determined Additional comments Please list the student's interests.(Required) Describe the student (including strengths and areas to improve).(Required)Describe successful strategies used with the student.(Required)Describe the student's home life.Please list any conditions (medical or otherwise) of which the agency should be aware of when looking for a potential mentor (e.g. behaviours).(Required) Please assess the student in the following areas.(Required)Self-EsteemNeeds ImprovementSatisfactoryGoodExcellentSelf-Control(Required)Self-ControlNeeds ImprovementSatisfactoryGoodExcellentResponsibility for Actions(Required)Responsibility for ActionsNeeds ImprovementSatisfactoryGoodExcellentListens Attentively(Required)Listens AttentivelyNeeds ImprovementSatisfactoryGoodExcellentCooperation with Others(Required)Cooperation with OthersNeeds ImprovementSatisfactoryGoodExcellentRespects Authority(Required)Respects Authority Needs ImprovementSatisfactoryGoodExcellentFollows Direction(Required)Follows DirectionNeeds ImprovementSatisfactoryGoodExcellentComments/Questions.(Required) Facebook Twitter Google+ LinkedIn
