Assessment Form - The Academy Builders

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Home
About Us
Training
Consultations
- Shop
Youth Mentorship
Contact Us

Home
About Us
Training

Home
About Us
Training

Consultations
- Shop
Mentorship
Contact Us

Consultations
- Shop
Mentorship
Contact Us

Youth Mentorship

Youth Mentor Program

Youth Information

First Name

Last Name

Gender

Male Female

Date of Birth

Age

Address

City

Postal Code

Cellphone Number

Home Phone Number

Email Address

Is the youth currently attending school?

Yes No

Current School

Grade

Languages Spoken

Families Cultural Background

Do You Need An Interpreter?

Yes No

Which best applies to the youth

Citizen Permanent Resident Refugee Other

Specify if other

Does the youth identify as a Newcomer?

Yes No

Is the youth on any medication that we need to be aware of?

Yes No

If Yes, describe

Any allergies?

Yes No

If Yes, describe

Does the youth have any emotional, mental, physical, or specific medical health conditions that we should know about?

Yes No

If Yes, describe

Is the youth in counseling or receiving services from Child Protective Services?

Yes No

If Yes, describe

Is the youth or family currently involved with Child Protective Services?

Yes No

What is the level of Involvement?

Family Enhancement Protection

office location

Phone Number

Social worker’s name:

Emergency Contact Information

Contact Name

Relationship

Phone No.1

Phone No.2

Parent/Guardian Information
where applicable and youth ages 12 - 17 Years old

Parent/Guardian's First and Last name

Relationship

Phone Number

Email Address

Languages Spoken

Do you need an interpreter?

Yes No

Other Parent/Guardian(s) Name(s) if any

Relationship

Phone Number

Getting to know the youth
This will help us with matching the youth with a compatible mentor

Why does the youth need/want a mentor?

Tell us about the youth’s personality and strengths

What would you say are some of the youth's challenges?

Is there anything you would like us to be aware of that would assist us in finding the right mentor for the youth?

Yes No

If yes, please describe

List some of the goals/changes the youth would like to achieve while in the program. This could either be academic, social, and personal skills, cultural connection, professional development, networking, communication skills, leadership skills, or other skills.

How did you hear about this program? Select all that applies.

The Academy Builders social media The academy builders email newsletter word of mouth other

Specify if other

By ticking on the checkbox bellow, you consent to receive services from The Academy builders

I agree to the terms mentioned above

Complete Name

Referral
To be completed by the referring Agency only

Referring Agency

Referred By

Phone Number

Email Address

Youth Mentorship

Youth Mentor Program

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