There are three stages to the matching process. Below are the forms necessary for each stage.
Stage 1- Requesting a Mentor
In Stage 1, the therapist will complete the appropriated request form based on client’s age or for a parent. See request forms below:
Child Mentor Age 5-16
TAY Mentor ages 16-25
Parent Mentor
Also required:
Completed Client Pre-Match Assessment form
PHI form
Stage 2- Securing a Match
Guidelines for meeting the potential mentor
Parent Match Agreement
Parent Match Permission (2 pages)
Client Medication form
Youth Questionnaire
ALSO: During the match the therapist will complete:
3-month Client Assessment
3-month Youth Questionnaire-at the appropriate time this form will be sent to the therapist by MHA-PT
Stage 3- Ending a Match
Client Readiness
Client End of Match Assessment
You may fax completed forms to MHA-PT to (714) 836-0356
NOTE: IF YOU CHOOSE TO SEND REQUEST VIA E-MAIL YOU MUST USE A PROTECTED PASSWORD!