Teacher/Staff Referral Form

Teacher/Staff Referral Form

Student Name: _________________________________

Age: _____ School: ________________________________ Grade: ____

Requested by (teacher/staff): ___________________________________

The child is being referred for assistance in the following areas (circle all that apply):

Academic Issues: ___ Behavior Issues ___ Study Habits ___

Criminal Activities ___ Family Concerns ___ Vocational Training ___

Social Issues ___ Other: _______________________________________________

Reasons why this child might benefit from a mentor: _____________________________________________________

___________________________________________________________________

What interest (in or out of school) does this child have? __________________________________________________

___________________________________________________________________

What strategies/learning models might be effective for a mentor/tutor working with this child? ___________________

___________________________________________________________________

On a scale of 1-10 (10 being the highest), rate the students level of:

Academic Performance: ____

Social skills: ____

Self-esteem: ____

Family support: ____

Communication skills: ____

Attitude about school/education: ____

Peer relation: ____

What specific subjects, if any, does the student need assistance with? _______________________________________

__________________________________________________________________

Additional Comments: __________________________________________________________________

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