Parent Mentor Program of Saskatchewan Parent Application

Transcription

1 Parent Mentor Program of Saskatchewan Parent Application Name: Date of Birth: Partner s Name: Date of Birth: Address: Postal Code: Telephone Home: Work: Cell: School: Name: Date of Birth Family Tree: Partner s Name: Date of Birth Children s Names Birth date and Ages Male/Female Address: Postal Code: Education: Telephone Home: Work: School Employment: Number: Can we leave a message? If pregnant, what is your due date? Work Number: Can we leave a message? Parent Mentor Program of Moose Jaw, Saskatchewan 1

2 Education: Employment: All about you and other neat stuff: What special interests or talents do you have? How would you describe yourself? If you had a whole day just to yourself what would you do? What are some of the reasons you would like to participate in the Parent Mentor Program? Parent Mentor Program of Moose Jaw, Saskatchewan 2

3 What do you expect to gain from this program? Are there special skills you would like to develop? (i.e. parenting, communication, budgeting, education, self-esteem etc.) Do you have support people in the community? (ie partner, parents, church, friends etc?) What are the specific qualities, skills or attitudes you would like to see in your mentor? Who was/is a positive person in your life? Why? Parent Mentor Program of Moose Jaw, Saskatchewan 3

4 If you have a partner (boyfriend, married, common law) please provide his name: What is the highest level of education you have completed? Do you want to continue your education? Yes No What do you usually do in your spare time? Watch TV/movies visit write listen to music Crafts art read spend time with animals Exercise computer other What would you like to do if you had more spare time? What are you good at? (What do you think and what do other people say) What do you like about yourself? Is there anything you would like to change about yourself? What is your biggest challenge being pregnant and or parenting? What is your biggest overall life challenge? Do you have a driver s license? No Learners License Parent Mentor Program of Moose Jaw, Saskatchewan 4

5 Do you have access to a vehicle? Yes No What transportation is available to you? Ride Bus Cab Walk Bike How did you hear about Parent Mentoring Program? Public Health Nurse Social Worker Family Member Friend Counselor Doctor Poster/Pamphlet Television/Radio Teacher Other Why do you want to participate in PMP? What kind of assistance from a mentor and/or the SMSP program would you find most helpful? New skills New Information Groups A role model A supportive friend Referrals to other services Relationships Resources (books, tapes, With peer s videos, online information) What do you hope to gain from participating in PMP (check as many as apply): PREGNANCY INFORMATION: learning about what is healthy for me and my baby PARENTING SKILLS: learning normal growth, development and behavioral expectations of children PERSONAL ENHANCEMENT: learning problem solving, assertiveness & decision making skills as well as increasing self-esteem and self-confidence Parent Mentor Program of Moose Jaw, Saskatchewan 5

6 FINANCIAL: assistance with budgeting (establishing priorities, planning for payment of debt, bills & purchases) EDUCATION: guidance with current education or seeking alternative educational opportunities EMPLOYMENT: help in relationship with employer and/or co-workers, preparation of resume, coaching for interviews HOMEMAKING/HOUSEKEEPING: guidance and assistance in developing skills in managing a home i.e. cleaning, organizing HOUSING: help finding a new place to live and making arrangements to move TRANSPORTATION: assist with making arrangements to get to appointments such as the doctor, job interview, etc. (mentor may occasional drive parent if willing and available) NUTRITION: shopping for food, information regarding nutrition, meal planning and preparation RECREATION: participating with and encouraging fun and leisure activities. RELATIONSHIP CONCERNS: help in exploring thoughts and feelings about significant others in your life (partner, parents, children, extended family, friends) and your part in these relationships; referring for counseling or groups if wanted ADVOCACY: support and advice regarding contact with organizations, departments, agencies, etc CHILD CARE: assistance and support in determining child care needs (babysitter, daycare) What type of person do you picture your mentor to be? (Age, religion, race, personality, etc.) Parent Mentor Program of Moose Jaw, Saskatchewan 6

7 How many hours each week would you expect to spend with a mentor? What days of the week and time of day would work best for you? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning afternoon evening How have you been feeling lately? Very Good Good Okay Bad Very Bad How is your healthy, generally? Very Good Good Okay Bad Very Bad Do you have any chronic illnesses: Yes No If yes, please explain Do you have any allergies: Yes No If yes, please explain Are you taking any prescribed mediations (include birth control): Yes No If Yes, please explain Do you smoke cigarettes Do you drink alcohol Do you take drugs Yes Yes Yes No No No If yes to any of the above, do you want to quit: Yes No If yes do you want help to quit: Yes No Parent Mentor Program of Moose Jaw, Saskatchewan 7

8 Is there anything else you would like us to know that we have not asked or that you think we should know? Do you know of anyone, other than yourself, who would be interested in participating in the Parent Mentor program, as a parent or volunteer? Name Telephone Number Name Telephone Number As a participant in the Parent Mentor Program, I understand and agree to: 1. Code of confidentiality 2. Attend all activities. If I am unable to attend I will notify my Mentor and/or the Parent Mentor Program Coordinator. 3. I acknowledge that the Parent Mentor Program is under no obligation to accept or match me with a mentor. All information and files are the property of the Moose Jaw Parent Mentor Program. Date Signature Parent Mentor Program of Moose Jaw, Saskatchewan 8