Silver Lining MentoringCommunity Based MentoringParticipant Application: Part 1

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This form is considered Part 1 of the Silver Lining Mentoring application for a community-based mentor (CBM). Please read the details below thoroughly before confirming. This form is used to clarify questions surrounding mentee eligibility for the Silver Lining Mentoring CBM program. Please fill out the following questions to the best of your knowledge. You may save the form and return later if needed.
Silver Lining Mentoring matches DCF-involved youth with a one-to-one, screened and trained volunteer mentor. This volunteer commits to meeting with that young person for a few hours per month for at least one year. This opportunity is specifically for youth:

7-22 years old at the time of enrollment
Impacted by foster care and adoption experience
Involved with Massachusetts Department of Children & Families (DCF)
Eligible for 3 months of Family Network funding
Wants a mentor

If the youth is not involved in DCF or eligible for funding, or you have additional questions, you may still complete the survey and a team member will contact you shortly. Please don't hesitate to contact SLM staff using intake@silverliningmentoring.org with any questions regarding this referral.

Privacy Policy Statement:

To evaluate effectiveness and make continuous program improvements, Silver Lining Mentoring collects demographic and survey information from the participants in our services. Information is entered into a secure database, Salesforce, that can only be accessed by program staff at Silver Lining Mentoring. Silver Lining Mentoring will never share a participant's personal information without explicit consent.

Program Acknowledgements

Yes, I agree to the above Privacy Policy Statement. I understand and agree to how Silver Lining Mentoring will collect and utilize data in conjunction with the Salesforce database.

I acknowledge that Silver Lining Mentoring does not provide therapeutic mentors and that their volunteers do not engage in treatment planning or behavior modification

I confirm that the youth is safe to engage in the public with a volunteer mentor

I confirm that the young person being referred is either presently involved with foster care or adoption, or has prior experience in foster care or adoption.

Page 2: Referrer Contact Information

Referrer Information

Please provide the contact information of the person completing this form.

Referrer First Name

Referrer Last Name

Referrer Phone Number

Referrer Email

What is your relationship to the participant?

Self, Parent/Foster Parent, DCF worker, Family Networks, Residential Staff, etc

Page 4: Providers & Caregivers Information

Guardianship and Caretaking Status

Is the participant currently involved with the Department of Children & Families?

Participant Legal Guardianship Status

Does the participant have a primary caretaker who supports their day-to-day activities?

DCF Department of Children & Families

DCF Social Worker

DCF Worker First Name

DCF Worker Last Name

DCF Worker Phone Number

DCF Worker Email

DCF Area Office

DCF Supervisor First Name

DCF Supervisor Last Name

DCF Supervisor Primary Phone

DCF Supervisor Email

Non-DCF Legal Guardian Information

Who has the legal authority to make decisions on behalf of this referred young person?

Guardian First Name

Guardian Last Name

Is the Guardian address the same as participant's?

YesNoIf participant's home address is the location where the Guardian is employed, please select "Yes."

Guardian Street Address

Guardian City

Guardian State

Guardian Zipcode

Primary Phone - Guardian

Email - Guardian

Please describe the relationship of the Guardian to the participant (ex. mother, father, adoptive parent)

Caregiver Information

Who is the individual who supports the youth day-to-day and will be the primary contact for the mentor?

Caregiver First Name

Caregiver Last Name

Is the caregiver address the same as participant's?

YesNoIf participant's home address is the location where the Caregiver is employed, please select "Yes."

Caregiver Street Address

Caregiver City

Caregiver State

Caregiver Zipcode

Primary Phone - Caregiver

Email - Caregiver

Please describe the relationship of the Caregiver to the participant (ex. mother, father, adoptive parent)

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Cell	Email
Mail	Phone - landline
Text Messages	Social Media
Video Calls	None of the above

Silver Lining Mentoring
Community Based Mentoring
Participant Application: Part 1

Page 2: Referrer Contact Information

Page 3: Youth Information

Page 4: Providers & Caregivers Information

Page 5: Additional Information