Child Reference Form - Professional Please answer these questions to the best of your ability. This information will be kept confidential. Child's name* First Last Date of birth* Date Format: MM slash DD slash YYYY Reference's name* First Last Your position*Institution/agency name*Who do you primarily work with guardian/child/family?*How long have you known this guardian/child/family?*Please describe the work you have done with this guardian/child/family.*Has your relationship with them ended? If so when and how successfully?*If you are still working with this family, how long do you expect to do so?*Please describe the child’s personality/behavior especially in terms of how he relates to adults and other children.*Please describe the child’s relationship with his guardian to the extent that you are aware of it.*What behavior difficulties has the child exhibited?*What interests does the child have?*What qualities/interests would be important in choosing a mentor for this child?*If your primary work is with the guardian, what is the nature of your work?*Is the guardian dealing with any issues that might prevent them from following the rules and guidelines of our program? (e.g. mental illness, custody arrangement, substance abuse, language barrier, etc.)*In your opinion, does the child have the ability to form a stable, positive relationship with a volunteer within the limits of our program?*In your opinion, is it appropriate for this child to have a mentor at this time?*Are you aware of any resources working with this child? Check all that apply:* School Counsellor Public Health Nurse MCFD Mental Health Child Care Worker Psychiatrist Psychologist Other Other*Are there any additional comments that you would like to make?By checking yes below, you agree that all the information above is true.* Yes
