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Youth Assessment
Company
Person Completing Form
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Placement
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Youth's Name
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Date
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Select One
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House Manager/Caregiver
Mentor
Youth
At the end of the last school year did the youth move on to the next grade level?
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Yes
No
If your mentee graduated from HS in the past 6 month, is he/she pursing a secondary education?
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Yes
No
Not Applicable/Still in HS
In the last six months, did any of the youth’s grades Improve by one grade letter?
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Yes
No
Did the youth miss more than 20 days of school this year?
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Yes
No
In the last six months, did the youth receive out school suspension or have a safety plan put in place?
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Yes
No
In the last six months did the youth use alcohol, tobacco or drugs?
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Yes
No
In the last six months did the youth run away from their placement? (AWOL)
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Yes
No
In the last six months has the youth had any arrest or involvement with law enforcement?
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Yes
No
Did the youth's self confidence increase?
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Yes
No