MM slash DD slash YYYY
Name (email) of Staff Member completing check-in:(Required)
Method of answering check-in questions:
Program Site

Match Participants

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

Six Conditions

Make sure to include preparation for match closure. Consider the following: 1. Confirm that all matches wrap-up at the end of the school year; 2. Discuss what they may say to their mentor; 3. Talk about how they would like to celebrate their match; and 4. How are they feeling about saying goodbye and recognizing those natural feelings? REMEMBER: 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 has been your favorite activity to do with your mentor since the last time we checked-in? Probe: What is your favourite memory with your mentor?
1A. Activity Expectations
Did you visit with your mentor every week? Probe: Are you happy with how often you’ve seen your mentor?
2A. Consistency Expectations
What do you like about having a mentor? Probe: On a scale of 1-10 how close do you feel to your mentor?
3A. Connectedness and Closeness Expectations
What have you learnt from your mentor?
4A. Youth Cenredness Expectations
How will you show your mentor that you have enjoyed the time together and that they are appreciated?
5A. Structure Expectations
Finish this sentence: “Having a mentor makes me feel...” Probe: Describe how having a mentor makes you feel.
6A. Duration Expectations

Big Three survey

BIG SOCIAL: Because of my Mentor, I am better at treating others with respect.
BIG WELL-BEING: Because of my Mentor, I am better at handling challenges.
BIG POSSIBILITIES: Because of my Mentor, I am better at trying new things and learning.

ISM Specific Questions

If the mentee has concerns or does not want to be matched with the same mentor next year, please provide details in box labelled "Additional information from mentee".
1. Is there anything you want to talk about or do you have any concerns?
2. Would you like to be involved in the program again for the next school year?
3. Do you want to have the same mentor again for the next school year?
Conclusion(Required)