Youth Assessment Form

Complete the online form below and then click Submit.

First name

Last name

Name you would like to be called:

Address

City | State | Zip

Phone

Parent first name

Parent last name

Parent Address

City | State | Zip

Parent Phone

Date of interview:

Month

Day

Year

Strengths | Weaknesses

What are some of the positive things you see in other youth your age?

What are you interested in? i.e. hobbies?

What is your idea of a family environment?

What do you fear?

What types of things make you feel happy? Or sad?

What types of things do you and family do together?

Family | Youth Needs:

What is your current living situation?

Do you have a job or ways that you make money to save?

What type of friends do you have? Of them which one is the closest and why?

Family History

What do you like best about your mom, dad, brother, sister, grandparents (only choose the ones that apply)?

Program Geared Questions

Whay are you attending this program?

What do you think that this program is supposed to do for you?

What types of ideas would you like to bring forth to the program to help others?

Disclaimer: This form is designed to get a perspective of what our participants are familiar with as it relates to life in general. There are not

any right or wrong answers. It is designed in no way to disregard a youth’s creditability or intelligence as it relates to our mentoring

program. It helps the program instructor to better design the correct programs and guidance to help our youth or young adults to obtain a

better quality of life as in relates to their current circumstances.

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