MM slash DD slash YYYY
Name (email) of Staff Member completing check-in:(Required)
Location of check-in:(Required)

Match Participants

Name of Mentee (first and last):(Required)
Name of Mentor (first and last):(Required)

Developmental relationships survey

1. Express Care
How often does your mentor show them that you matter to them?
1A. Do you want your mentor to "Express Care" more, less, or keep it the same?
2. Challenge Growth
How often does your mentor encourage you to be your best?
2A. Do you want your mentor to "Challenge Growth" more, less, or keep it the same?
3. Provide Support
How often does your mentor help you get things done?
3A. Do you want your mentor to "Provide Support" more, less, or keep it the same?
4. Share Power
How often does your mentor listen to your ideas and take them seriously?
4A. Do you want your mentor to "Share Power" more, less, or keep it the same?
5. Expand Possibilities
How often does your mentor connect you with new people, places or ideas?
5A. Do you want your mentor to "Expand Possibilities" more, less, or keep it the same?

Six Conditions

Please check-in with the mentee about each of the Six Conditions but case-note only what's not working, not meeting expectations, needs follow-up or is exceptional!
What activities do you do with your mentor? How often are you meeting with your mentor and where are activities taking place? What activities are most enjoyable? How do you decide on activities to do with the mentor? Are the activities within or outside your comfort zone?
1A. Activity Expectations
Have you been seeing your mentor weekly? Probes: How easy or hard has it been to keep meetings with your mentor? Do you think you are getting enough support from BBBS for your match? Is anything coming up at school or home that may impact match meetings?
2A. Consistency Expectations
Describe your friendship with your mentor? On a Scale of 1 to 10, how do you feel your match is going? What would make it 10/10? Probes: Do you plan activities with your mentor? How often? How does your mentor show you that you have their full attention? Are you finding it is getting easier to talk to your mentor?
3A. Connectedness and Closeness Expectations
What kind of things do you and your mentor talk about? Probe: Do you feel comfortable talking to your mentor about things that are bothering you? Why not? Do you feel like you are at the center of this program? Do you believe that the program is designed to meet your needs and support your growth? Would you change anything about this mentoring program?
4A. Youth Cenredness Expectations
Does your mentor respect your boundaries? Do you respect the boundaries that you and your mentor have set? Do you think you and your mentor are working well together? Do you feel like your mentor is helping you to reach your goals?
5A. Structure Expectations
Are you happy with this program? How can we make it better? Have there been any surprises in what has been expected from you as a mentee/caregiver? Are you still wanting to participate in this program?
6A. Duration Expectations

ISM Specific Questions

If the mentee answers YES to any of the questions below, please describe their response in box labelled "Additional information from mentee". These questions provide an opportunity to discuss boundaries and programs rules, if necessary, as well as any changes that the mentee wants in their match.
1. Have you had contact with your mentor outside of school (in-person, by email, over social media, gaming platforms, etc.)
2. Is there any activity that you want to do with your mentor before the end of the school year?
3. Is there anything you want to talk about or do you have any concerns?