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OreMi Mentoring Program Mentee Referral Form

Instructions:

  • This referral is to be completed by an Adult/Parent/Guardian/Agency Worker. All information on this referral will be kept confidential and will be used solely by the personnel at Family Support Services of the Bay Area for administrative purposes only. Note: Submitting a referral form to the OreMi Mentoring Program at does not guarantee acceptance or matching in our program.
  • If you use our online form, please provide answers to all fields.
  • If you choose to use the printable form, please print clearly in blue or black ink. Please deliver in person, fax mail or email your completed referral form to:

OreMi Mentoring Program
Family Support Services of the Bay Area
401 Grand Avenue, Suite 500 Oakland , CA 94610
Tel: 510-834-2443 Fax: 510-834-1548 Email: oremi@fssba-oak.org

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Date: Referred By: Contact Phone:

Name of Referring Agency or School:

Youth First Name: Youth Middle Name: Youth Last Name:

Date of Birth: Gender: Male Female Transgender

School: Current Grade Level:

Parent/Guardian Name: Relationship to Childe:

Work Phone : Home Phone: Cell Phone:

E-Mail:

Street Address:

City:

State: Zip:

Name of Incarcerated Parent: Expected Release Date:

Relationship to Child:

Is youth aware of parent's incarceration? Yes No
If no, please explain:

:

Why do you feel this youth might benefit from a mentor?

Is there any other information we should know about this youth?

(please click only once)

OreMi Mentoring Program
Family Support Services of the Bay Area (FSSBA)
401 Grand Avenue, Suite 500
Oakland, CA 94610
Tel: 510-834-2443 ◊ Fax: 510-834-1548 ◊ Email: oremi@fssba-oak.org
Thank you!

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