Your Name * First Name Last Name Youth Name First Name Last Name Are you still interested in being matched with a mentor? Yes No Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Best way to contact you? Phone call Text Email Who does your child receive mental health services with? (Please list name, agency, contact info.) If your child no longer receives mental health services, your child may not be eligible for mentoring services. Please contact a program coordinator for more information. What school does your child go to? What grade? Have there been any environmental or behavioral changes recently? Does your family receive skill-building or family support services through a different agency? Yes No Are you interested in receiving any support or resources? Yes No What kind of activities or events would your child be interested in attending? Are you comfortable with your child meeting in person for mentoring activities? Yes No Could you transport your child for mentoring activities if a volunteer could not drive? Yes No Do you or your child have any mentor preferences? Female Male No Preference Is any member of your family involved in the military? If yes, would you like information about our Compeer CORPS program? Thank you!
