Your Email (required)

Your Name:

Date (e.g. 2015-12-31) of Conversation (required)

Mentee Name (required)

Do any Adults
Help with school work?Say something nice after doing something good?Pay attention to what’s going on in your life?Get on your case if you mess up or make a mistake?Offer help if you feel physically threatened?Offer help in an emergency?Offer advice about personal problems?Offer help if you were really upset or mad?
Do any of these Apply:
I pay attention in classI often come to class unpreparedI don’t try very hard in schoolI work very hard on my schoolwork
What is Important?
Doing the best I can in schoolDoing what I believe is rightStanding up for what I believeTelling the truth, even when it’s not easyAccepting responsibility for my actionsDoing my best when I have a job I don’t likeHelping to make the world a better placeGiving time or money to better it for others
Do What in Difficult Situations?
Go over in my mind what I will say or doForget the whole thingCome up with a couple of different solutionsTry not to act too hastily or follow my first hunchTry not to act too hastily or follow my first hunch.Talk to someone to find out more about the situationTry to see things the other person’s point of viewAsk someone I respect for adviceGo on as if nothing is happeningWait to see what will happen before doing anythingTalk to someone about how I’m feelingAccept sympathy and understanding from someoneTalk to someone who can help solve the problemMake a plan of action and follow it

Other Impressions

Intake Survey

Sample dialog with the Youth:

"This survey will help us learn about you and the other youth who are participating in the mentoring program. It is important for us to learn as much as we can about what you want to get out of your participation and how we can improve the program to make it even better next year. Please try to  answer each question as honestly as you can.

There are no right or wrong answers, so please do not answer the questions based on what you think I want to hear. I will be the only one to see how you answer the questions and the answers are confidential."


Note to mentor: A copy of this intake form will be sent to your email.

Please complete this form during or soon after the first conversation. These questions are only a guide to help get things started and are not required to be followed if the Mentee is suitably engaged. If you must fill in the Q&A's based only on impressions then that is acceptable and better than nothing but that fact should be noted in the body of the email.

The Status: of the situation allows us to manage the situation with regards to followup, scheduling future conversations or simply closing the case. Followup conversations should be reported using the Evaluation page.

Usage of Status:
Concluded - likely means there is not going to be another conversation.
Satisfactory/unsatisfactory is your opinion as to the issues raised having been addressed
Reschedule - after a missed, late or short conversation (put details in the body of the message)
Schedule - a satisfactory conversation; mentee wants another (time/date in the body)
Followup - your intention to initiate a followup with mentee to satisfy yourself everything is ok
Other - detail in body of message