Big Brothers Big Sisters Lincoln: Client Referral Form

Big Brothers Big Sisters Lincoln:
Client Referral Form

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Big Brothers Big Sisters Lincoln
School/Agency Referral Form
(One form per child)

FOR PROFESSIONAL USE ONLY-NOT FOR FAMILIES

Date

Name of Youth

Race/Ethnicity

Date of Birth

Youth's Gender

Youth's Preferred Pronouns

Youth's School

Current Grade

Name of Parent/Guardian(s)

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Is this youth from out-of-home placement?

YesNo

Out of Home Placement

Guardian Name(s)

Guardian Address Line 1

Address Line 2

Guardian City

Guardian State

Guardian Zip Code

Guardian Work Phone

Guardian Home Phone

Guardian Place of Employment

Name of Person Making Referral

Title

Agency/School

Agency/School Address Line 1

Address Line 2

Agency/School City

Agency/School State

Agency/School Zip Code

Agency/School Phone

What is your relationship with the child?

Have you informed the parent(s)/guardian(s) of this referral?

YesNo

Have you informed the child of this referral?

YesNo

Extra Details

Why does this child need a mentor?

Describe any behaviors observed or noted.

Are there any special needs? (e.g. Special Ed, abuse/neglect, etc.)

Are there any other services the child/family may be receiving?

Have you referred this child to any other agencies?

Anything else we need to know about the child or family system?

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Contact Information