Child Safe Michigan Mentorship Youth Referral Packet Directions: If the child is an MCI ward the DHS worker has to sign as parent/guardian. If the child is a TCW the parent needs to sign the paperwork. Youth Criteria: Ages 7-23 Reside in a foster placement (home, relatives) or family has had a CPS case open. Youth may also have been adopted. Free of attempts/serious threats of suicide within past year Cannot have any criminal charges pending Agree to stay substance/alcohol free during year long commitment But most importantly, the youth has to want a mentor! Packet Includes: When emailing packet back please keep each form on it’s own piece of paper. 1.

Referral- Completed by DHS/Foster Care Worker

2. Terms of Agreement- Must be signed by the referring worker 3. Legal Guardian Consent- Must be signed by the Legal Guardian (If the child is a MCI ward, the DHS worker has to sign as parent/guardian. If the child is a TCW, the parent needs to sign the paperwork) 4. Emergency Information form- Must be signed by the Legal Guardian. 5. Photo Release form- Must be signed by legal guardian, only if child has been adopted and no longer is in the system. 6. Contact Information Release form- Must be signed by the legal Guardian 7. Mentee Application- Must be completed by the youth, adults may assist. PLEASE, encourage youth to be as detailed as possible. In order for us to make the best possible match we need as much information on the youth as you can provide. You may also include the updated USP with this referral. A mentor/mentee match is assessed by mentor/mentee personalities, interest, preferences and location. This process is taken seriously to ensure that the most effective matches are made. Mentors commit for at least one year, and spend 2-4 times a month with the youth, with the hope that the relationship will go well beyond a year. Please mail or fax the completed packet when you are ready to refer a youth. Any questions please contact the mentorship program staff at 248-353-0921

Youth Application 1

MENTOR PROGRAM

Mentee Referral Form Please fill out this form and return with the youth application, parental consent, terms of agreement and the emergency consent form. The forms may be faxed for prompt attention; however, the originals must also be mailed. Please be sure all forms are filled out completely and accurately and keep copies for your files. Date: ________________________

Youth’s Name: ______________________________________________________________________________ Age: _______________

Male: _____ Female:_______ Other: _____________________

Race/Ethnicity: ____________________________ Type of Placement:_____________________________________________________________ *Please note: If the youth resides in a residential facility, please check whether or not they have their own Mentor Program.

Type of Wardship:_____________________________________________________________ Current Foster Parent/Guardian:_______________________________________________ Address where youth currently resides:___________________________________________ City:_________________________

State: __________

Zip: ___________________

Phone Number: _______________________________________________________________ Behaviors and/or special needs:__________________________________________________ Diagnosis (if any):______________________________________________________________ How did you hear about our agency? _____________________________________________ Does the youth have an Incarcerated Parent/Caregiver: ( ) Yes

( ) No

Name of the parent incarcerated: _______________________________________________________________________ Facility where Incarcerated: ________________________________________________________________________ Relationship to youth: ( ) Mother

( ) Father

( ) Other, specify: ______________

Youth Application 2

Please provide a brief history on this youth (ex: how long has he/she been in care, what brought the youth into care, etc) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please describe the youth’s behavior in the school setting (ex: truancy, bullies or is being bullied, poor attention span, grades below a C, inappropriate behaviors, does the child follow rules, etc)_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Youth’s behavior in the home setting (ex: follows rules, truancy, rude and mean to others, sexually acts out, etc) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Youth’s behavior in the community (ex: Involved with the legal system, on probation, damages, property, shoplifts, etc) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Youth’s moods and emotions (ex: sad, withdrawn, anxious, irritability, worries, many fears, etc)___________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Self-Harmful Behaviors (ex: suicidal gestures, cutter, etc)_____________________________________

Youth Application 3

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Substance Abuse Use (ex: alcohol, drugs, prescription drugs, etc)________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Other: ______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Agency Information Referring Agency:_______________________________________________________ Address: ______________________________________________________________________ Worker: ______________________________________________________________ Phone:_____________________________ E-mail:____________________________ Fax: ______________________________________

DHS Worker:___________________________________________________________ Address: _______________________________________________________________________ Phone: ______________________________________E-Mail: ____________________ Fax:____________________________________________________________________

Child Safe Michigan Phone: (248) 353-0921 Fax: (248) 307-9595 30680 Montpelier, Suite 250 Madison Heights, MI 48071 Mentor Coordinator: Kelly Auwers E-mail: [email protected] Mentor Program Supervisor: Jennifer Brubaker, BS [email protected] Director: Ann Marie Lesniak, LMSW E-mail: [email protected]

Youth Application 4

Terms of Agreement The referred youth must be age 7-23 and reside in a foster placement in Wayne, Oakland or Macomb County. The youth can not have any criminal charges pending. The referred youth must be free of any attempts or threats of homicide or suicide within the past year. The referred youth must be alcohol and drug free at the time of the referral and throughout the mentor match. The youth’s assigned worker will attend a scheduled meeting between youth, guardian, mentor coordinator and worker. After the meeting, the mentor coordinator will make an assessment of whether or not the youth is appropriate for the mentor program. Our number one priority is the safety of our volunteers and children. Child Safe Michigan will match the identified mentee with an approved mentor. The mentor will have contact with the family in relation to scheduling and completing outings with the mentee. The mentor coordinator will complete a monthly check in with the case worker, mentor, youth and guardian to ensure program rules and polices are being followed. The mentor coordinator will complete a quarterly report on the match progress and will submit to the referring worker. The mentor will communicate with the Child Safe Michigan mentor coordinator regarding the match and any concerns. The assigned worker must notify the mentor coordinator immediately if any changes occur in the following: new assigned worker, change of placement, change of contact information and scheduled PPC meetings. The assigned worker must return calls back to the mentorship program staff so we can check on the progress of the youth. The Child Safe Michigan mentor coordinator will contact the mentee’s assigned worker regarding any concerns with the mentee and/or the family. If any concerns arise regarding the mentor, the mentee’s assigned worker will contact the Childhelp mentor coordinator. If information is wanted about the status and progress of the match, the mentee’s assigned worker can contact the Childhelp mentor coordinator for the information. The child’s guardian will be required to sign a parental consent for release of information. The mentor will receive ongoing training and support from Child Safe Michigan.

Youth Application 5

_____________________________________ Referring Worker’s Signature

________________________ Date

_____________________________________ Child Safe Michigan Program Staff Signature

________________________ Date

LEGAL GUARDIAN CONSENT

I ,__________________________, am the parent/legal guardian of _______________________ and agree to have him/her participate in the Child Safe Michigan’s Mentoring Program. I understand that the Child Safe Michigan’s Mentoring Program is community based and offers the youth (ages 7-23) the chance to develop a relationship with a positive, responsible adult, other then an authority figure, who then becomes a friend, role model and advocate for the youth. This caring, consistent relationship leads to increased self-esteem, improved social skills, additional opportunities for success in life, and an improved outlook on the future for the youth. The program is community based, which means that the outings and activities between the mentor and the youth occur out in the community. The youth and the mentor plan activities that can be related to education, career exploration, life skills development, game playing and going to sporting events, entertainment or cultural events. I understand that the mentor has successfully completed a screening process, which included a FBI fingerprint check, a Michigan State criminal clearance, a Children Protective Services clearance, a Sex Offender registry check a driving record check, provided proof of a valid driver’s license/car insurance, an interview and orientation with mentor coordinator and 5 hours of training. I understand that the mentor will be matched with the youth for one year and outings will be 2-4 times per month. I understand that information regarding ___________________________ will be shared by the referring agency to the Childhelp mentor coordinator and the mentor to assure a good match is made. Information that will be shared includes abuse/neglect/delinquency history, any medical diagnosis, and typical behaviors. In addition, I understand that the youth and the person he/she lives with will complete a prematch and post-match survey, which will include questions about grades, school, self-esteem, social skills, problem solving and feelings about the future. The Mentor Program Supervisor, Jennifer Brubaker, is responsible for monitoring the mentoring relationship and can be reached at (248) 353-0921. By signing below I am giving consent for ________________________ to participate in the Child Safe Mentoring Program. I have read, understood, and agree to the information stated above and I have received a copy for myself.

_______________________________________________ Parent/Legal Guardian’s Signature

______________________ Date

Youth Application 6

________________________________________________ Child Safe Michigan Program Staff Signature

_______________________ Date

Emergency Information Child’s full name: ___________________________________________DOB:_______________________ Parents/Legal Guardan:___________________________________________________________________ Street Address:_________________________________City:_____________________________________ Home Phone:______________________Cell Phone:_________________Work Phone:________________ Non-parent Contact/Relationship (in case of emergency)_________________________________________ Phone number (s): _______________________________________________________________________ Street Address:______________________________________City:________________________________ Child Health Questions: Please State allergies (if any):__________________________________________ Medications:___________________________________________________________________________ Child’s Physician/Clinic:_____________________________________Phone:_______________________ Preferred Hospital for Treatment____________________________________________________________ Insurance Name/Number__________________________________________________________________

I hereby give my permission to Child Safe Michigan staff and volunteers to secure emergency medical and/or surgical treatment (non-emergency treatment or elective surgery are not included) for the above named minor child while in their care. ________________________________________________ Signature of Parent/Guardian

___________________ Date

________________________________________________ Signature of Child Safe Michigan Staff

____________________ Date

30680 Montpelier, Suite 250 Madison Heights, Mi 48071 248-353-0921 Office Care Link 1-888-711-5465 Children’s Protective Services 1-800-942-4357 Jennifer Brubaker’s Cell Phone 586-260-1412 or Ann Marie Lesniak, Supervisor, Cell Phone 248-520-6710 (Emergencies Only) Youth Application 7

PHOTO RELEASE FORM Child Safe Michigan or various other media may choose to take pictures or videotape participants in Child Safe Michigan Mentor Program activities. These images may be used for Child Safe Michigan displays, brochures, newsletters, archives, news releases, publicity and Web sites. I hereby grant permission to Child Safe Michigan to take and reproduce photographs and videotapes for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by Child Safe Michigan .

______________________________________________________________________ Print Child’s Name _________________________________ Printed Parent/Guardian Name

__________________________________ Parent/Guardian Signature & Date

Address:_______________________________________________________________ City: ___________________

State: ________________

Zip: ________

Youth Application 8

Contact and Information Release (To Be Completed by the Parent/Guardian)

Youth’s Name: _________________________________ Date: __________

I authorize Child Safe Michigan to obtain any needed information regarding my child from his school staff, including academic and behavioral records. Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match. ____________________________________________ Parent/Guardian Signature

_____________ Date

Parent/Guardian Name: Address_______________________________________________________________________ City______________________

State_________

Zip___________

Youth Application 9

MENTEE APPLICATION

Date:

________________________

Name:

_______________________________________________________________ (First)

Address:

(Middle)

(Last)

________________________________________ (Street)

________________________________________ Phone:

(City)

(Zip Code)

__________________________

Cell Phone: ______________________

Youth Email: ______________________________________________________________ Who Do You Live With?_____________________________________________________ (name and relationship) Siblings ___________________________________________________________________ (name(s) and do they live with you?)

Birth Date: __________

Age:______

Religion: ______________________

Sex:

M F

Race/Ethnicity:_______________________

Name of school:___________________________________________________________ Current grade: ________________________________ Average grades: _______________________________ Best thing(s) about school: ____________________________________________________ ___________________________________________________________________________ Worst thing(s) about school:___________________________________________________ ___________________________________________________________________________ School activities:_____________________________________________________________

Youth Application 10

Youth Application 11

How would you describe yourself?________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

What are your interests and hobbies?_____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Have you ever attended a church? ______________What was the name of the church?_______________________________________________________________________

Have you ever had a mentor?____________________________________________________ Do you remember that mentors name? Who?______________________________________ Why would you like a mentor?___________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you have a preference for the kind of mentor you’d like? (Black/White/Hispanic; age; etc) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Are there any days or times you will not be able to meet with your mentor? (Visits with family, therapy, sports, activities, etc) ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ By signing below, I am stating that all of the above information is true to the best of my knowledge: _______________________________________________ Mentee’s Signature

_________________ Date 12