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 Ethnicity (We ask about ethnicity to create mentor pairings that support cultural understanding and shared experiences. This is optional and confidential).Has the student confirmed they want to participate in the program and have a mentor? If no, please explain.(Required)Does the student have frequent absences? If yes, please explain.(Required)Does the student have behaviours that put themselves or others in the program, including staff and volunteers, at risk? If yes, please explain.(Required)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?(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personality (please check any that best describe the student).(Required) Outgoing Passive Active Friendly Talkative Shy/Withdrawn Independent Helpful Quirky Determined Additional commentsPlease list the student's interests.(Required)Describe the student (including strengths and areas to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)By clicking Submit, I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area's Privacy and Confidentiality Policy. Share: Facebook Google+ LinkedIn
