2025 LL Mentee Referral Form

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Life Launch Mentee Referral Form

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AGENT INFORMATION

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Date *

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Name of person making this Referral *

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Agency Name *

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Referral's Address: *

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Referral's Office Phone *

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Referral's Cell Phone *

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Referral's Email *

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How long have you known the youth? *

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Relationship to youth

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If other, describe

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YOUTH INFORMATION

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First Name *

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Last Name *

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Gender *

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WIT Age *

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Birth Date *

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Phone *

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Current Residence *

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Name of residence

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Address 1 *

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Address 2

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City *

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Partner State *

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Zip *

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DHS CASEWORKER INFORMATION

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Caseworker First Name

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Caseworker Last Name

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Caseworker Phone Number

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Caseworker Email

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CARETAKER INFORMATION

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Caretaker First Name *

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Caretaker Last Name *

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Caretaker's Address *

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Main Phone Number *

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Alternate Number *

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Caretaker's Email

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OTHER QUESTIONS

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In your opinion, how will the youth benefit from having a Life Launch support team mentoring him/her? (Your main reason(s) for referring this youth.) *

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In your opinion, what are the youth's strengths? *

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How many foster placements has the youth had? *

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Does the youth have a history of running away from placements? *

Yes

No

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If yes, how often has he/she run away in the past 3 years? *

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When was the last time he/she went AWOL? *

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Life Launch Referral Form - page 2

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MEDICAL / BEHAVIORAL HEALTH

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Does the youth have a history of: *

Neglect

Physical Abuse

Sexual Abuse

None of the above

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Does the youth have a history of sexually acting out? *

Yes

No

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If yes, please explain.

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Are there any past or current behavioral issues we need to be aware of that could affect the success of the mentoring process? *

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FAMILY HISTORY

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Have the biological parents' rights been terminated? *

Yes

No

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If parental rights exist:

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How often does the youth have contact with his/her bio-parents? *

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Does the youth have siblings: *

Yes

No

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If so, does he/she have contact with them? *

Yes

No

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