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First and Last Name:

Email:

Phone Number:

Parent(s)/Guardian(s) First & Last Names:

In case of an emergency, Olivia should contact (Name & Number):

How old are you and what grade are you currently in?

What brings you to mentoring at this time? Please check off what applies:

Relationship problems or building

Problem solving skills

Self-esteem, advocation, and confidence

Emotional regulation techniques

Emotional understanding, identification, and vulnerability

Social skill learning

Other

Have you been diagnosed with any mental health concerns in the past? If so, what?

Have you ever had suicidal behaviors. suicidal thoughts, or self-harmed? If so, when did this happen and what was the course of treatment?

What are preferred days/times for sessions? Do you want to meet on a weekly, bi-weekly, or monthly basis?

Child’s First & Last Name:

Parent(s)/Guardian(s) First & Last Names:

Parent(s)/Guardian(s) Email(s):

Parent(s)/Guardian(s) Phone Number(s):

In case of an emergency, Olivia should contact (Name & Number):

How old is your child and what grade are they currently in?

What brings your child to mentoring at this time? Please check off what applies:

Has your child been diagnosed with any mental health concerns in the past? If so, what?

Has your child ever indicated suicidal behaviors. suicidal thoughts, or self-harm? If so, when did this happen and what was the course of treatment?

What are preferred days/times for sessions? Do you want your child to meet on a weekly, bi-weekly, or monthly basis?

Resources:

- 988 suicide or crisis lifetime ~ call, text, or chat the number to speak with a professional (24/7)

- Call 911 or go to the nearest emergency room

Services