Reach & Rise Mentee Application - The YMCA of Greater Birmingham: For A Better Us

If you have any questions, please contact the Program Director:

Brittany Lindsey
YMCA of Greater Birmingham Al
2400 7th Avenue North
Birmingham Al 35204
Phone: 205-223-1084
Email: blindsey@ymcabham.org

YOUTH INFORMATION

Age*

Please enter a number greater than or equal to 21.

Date of Birth*

Personal Gender Pronoun

Relationship to Youth*

Relationship to Youth

Home #

Work #

Cell #*

Youth's School*

School City:*

Youth's Grade*

REFERRAL INFORMATION

Referral Date*

Agency/Program/Relationship to Youth*

Phone #(s)*

Best Times to be Contacted*

FAMILY INFORMATION

Military Type*

(If Yes, add details below)*

REFERRAL INFORMATION:

Other Reason(s) for Referral

Describe the reason(s) for the referral to the mentoring program. Any recent changes with the youth noticed? Any recent changes with youth’s family or living situation? Any specific challenges or difficulties? If so, what and when did they begin?*

What are some goals you think would be good for the youth? What could improve the youth’s life?*

What would the youth say is the reason for being referred? What would the youth see as a goal?*

If yes, where?*

If no, explain?*

What are the days and/or times youth is available to meet weekly with a mentor?*

If yes, when? What was their response/are they interested in having a mentor for their youth?*

What are the youth’s strengths, skills, hobbies, interests?*

School Information: What do the teachers say about the youth? How are grades?*

If yes, explain?*

Peer Relationships: How does youth relate to peers? Any significant relationships? Any difficulties getting along well with peers? Any specific age groups youth relates best with?*

If yes, where? When? For what reasons?*

Family History: Any changes/stressors for youth/family (moves, deaths, births, remarriage, separations/divorces, witness any accidents, trauma, domestic violence, etc.)? Who does youth primarily live with? Any specific custody/visitation arrangements if parents are divorced/separated? Who is most actively involved with the youth? What are relationships between family members like?*

Are there any specific cultural issues for youth/family that would be helpful to know?*

Any serious past or present medical conditions, illnesses, injuries, surgeries, hospitalizations, ongoing treatment, etc. for youth or family?*

If yes, what kind & what frequency?*

If yes, what & when?*

If yes, when?*

If yes, when & what happened?*

If yes, when and is it ongoing?*

If Yes, when & why?*

Reach and Rise Mentee Application

Reach & Rise Mentee Referral

YOUTH INFORMATION

REFERRAL INFORMATION

FAMILY INFORMATION

REFERRAL INFORMATION:

Find your
fitness at
the Y

Find your
friends at
the Y

YMCA of Greater Birmingham

Reach and Rise Mentee Application

Reach & Rise Mentee Referral

YOUTH INFORMATION

REFERRAL INFORMATION

FAMILY INFORMATION

REFERRAL INFORMATION:

Find your fitness at the Y

Find your friends at the Y

YMCA of Greater Birmingham

Find your
fitness at
the Y

Find your
friends at
the Y