In-School Mentoring Referral Form - Big Brothers Big Sisters of London and Area

About You

Name(Required)

First Last

Your Title (e.g. School Support Counsellor)(Required)

Your Phone Number(Required)

Your Email Address(Required)

School Nutrition Break Time(s)(Required)

About the student

If the student is already matched with a mentor in our Community-Based program, they are not eligible for an In-School mentoring match.

Does the student meet the following eligibility criteria to participate in Big Brothers Big Sisters of London and Area programming?(Required)

The child must be able to communicate and manage self-care independently (i.e., toileting, hygiene).

The child must be able to comprehend safety messages delivered by BBBSOLA staff through a training program.

The child does not have behaviours that put themselves or others in the program, including staff and volunteers, at risk.

The child must be able to build a relationship with an adult mentor that is positive, healthy, and respectful of boundaries.

If you are unable to check all of the boxes above, please do not proceed with submitting a referral. We are unable to provide programming to children who do not meet the eligibility criteria. We recognize our scope is limited, and we cannot meet all children's needs. Our mentors are volunteers in the community, not professionals in the field. These guidelines are in place to ensure that our programs are safe for all volunteers, youth, staff, and families.

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)

On average, how many days a week does the student attend school? Do they have frequent absences? Please explain.(Required)

Successful mentoring relationships are built through regular, ongoing contact. Students referred to the program should be able to participate consistently and commit to meeting with their mentor on a weekly basis. If a student has frequent or ongoing absences that would significantly interfere with regular participation, the program may not be an appropriate fit at this time. The program is intended to support students who are able to participate consistently, it should not be used as an incentive or strategy to encourage a student to attend school.

Does the student understand and agree to miss one recess each week to meet with a mentor?(Required)

Yes

Does the student have any behaviours, needs, or circumstances that the agency and/or a volunteer should be aware of?(Required)

This information helps us understand the student more so that we can make the most appropriate match and ensure the volunteer is prepared to support the student effectively.

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)

Additional comments

Please list the student's interests (please be specific if possible).(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.(Required)

Please assess the student in the following areas.(Required)

Self-Esteem

Self-Control

Responsibility for Actions

Listens Attentively

Cooperation with Others

Respects Authority

Follows Direction

Comments/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.