11821 State Route 160, Vinton, OH 45686
740.245.3051
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Home
FOH Blog
Events
Services
Prevention
Field of Hope Resiliency Program
Field of Hope Treatment Options
Inpatient Treatment
PHP/Reentry
Sober Living
IOP
Special Groups
Team
Employment
Giving
Testimonials
History
Mentee Referral Form
Please enable JavaScript in your browser to complete this form.
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Step
1
of 3
Youth's Information
Name
First
Middle
Last
Age
Grade
School
Requested By
Position
Phone Number
Next
Additional Information
The child is being referred for assistance in the following areas (check all that apply):
Academic Issues
Attitude
Behavioral Issues
Delinquency
Family Issues
Peer Relationships
Self-Esteem
Social Skills
Special Needs
Study Habits
Vocational Training
Other
If "other" is checked above, explain:
Why do you feel this youth might benefit from a mentor?
What particular interests, either in school or out, do you know that the child has?
What strategies/learning models might be effective for a mentor working with this youth?
Next
Youth Assessment
On a scale of 1 to 10 (10 being highest), rate the student's level of:
Academic Performance
Selected Value:
0
Social Skills
Selected Value:
0
Self-esteem
Selected Value:
0
Family Support
Selected Value:
0
Communication Skills
Selected Value:
0
Attitude About School/Education
Selected Value:
0
Peer Relations
Selected Value:
0
With what specific academic subjects, if any, does the student need assistance?
Additional Comments:
Name
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