Level Ground Reentry Mentoring Program

Mentor's name:

Mentor's email:

Mentee's name:

Your Mentor Advisor:

Date of last meeting (mm/dd/yyyy):

Mentee's current location:

Prison

Work Release

Day Reporting

DOC

Halfway House

Probation (in the community)

Other

Other:

Mentee's address:

Address Line 2:

City:

State:

Zip code:

Mentee's phone:

How many hours did you spend with your mentee this week? (Include telephone calls email exchanges in-person visits):

1 hour or less

2 hours

3 hours

4 hours

5 hours

6 hours

Would you consider this week's mentoring time your weekly average?

This week was average

This week was more than average

This week was less than average

Where did these meetings occur? (Check all that apply)

In Walker State Prison

At the mentee's home

At a restaurant or coffee house

Shopping at various merchant (groceries dry goods etc.)

Recreation center park hiking trail etc.

Church

Community event

Accompanied mentee who was fulfilling his/her criminal justice obligation

Accompanied mentee running personal errands

In transit (my car)

What happened during your meetings this week? (Check all that apply)

Spoke in depth about serious issues

Spoke casually

Recreated (athletics sporting events theater movie played games/cards etc.)

Met for a meal coffee snack

Attended church services

Helped navigate criminal justice system

What was the primary need(s) of your mentee at last meeting? (Check all that apply)

Someone to talk to

Problem solving

Transportation

Food

Housing

Clothing

Medical / Dental / Mental Health and Treatment

Substance use and treatment

Crisis intervention (violence arrest emotional breakdown intoxication)

Employment / job hunting

Education and/or skills training

Parenting issues

Relationship issues (friends family partner)

Financial concerns

What topics have your explored with your mentee during this past week? (Check all that apply)

Nothing in particular just chit-chat

Criminal justice involvement

Emotional needs

Employment concerns

Educational concerns

Self esteem issues

Problem solving / goal setting

Parenting and childcare

Healthy relationships (family friends)

Sobriety

Spirituality or religion

Financial management

Housing needs or concerns

Medical health treatment

Dental health treatment

Mental health treatment

What resources did your mentee utilize to meet his/her needs during this week or since the most recent meeting? Include any resources/services that the mentee is utilizing on an ongoing basis? (Check all that apply)

Church

Food resources

Homeless shelters

Housing services

Employment services including traiing programs

Education/skills training

Specialized treatment providers (mental medical dental health)

Court mandated classes

Sobriety meetings

Public transportation services

Recreation group

How would you characterize your mentee's emotional state at your last meeting? (Check all that apply)

Content

Positive

Determined

Negative

Stressed

Fearful

Agitated

Anxious

Depressed

Impulsive

Withdrawn

Resistant

Neutral

How would you characterize your mentee's mental state at your last meeting? (Check all that apply)

Clear thinking

Thoughtful

Responsible

Focused

Future oriented

Fatalistic

Confused

Refusing accountability

Rationalizing poor decisions

Unable to focus

Remorseful

How would you characterize your mentee's physical state this week? (Check all that apply)

Clean

Unwashed

Appropriately dressed

Inappropriately dressed

Appears physically healthy

Appears physically unhealthy

Eating well

Not eating well

Have your worked on an Action Plan with your mentee? An Action Plan is always a work in progress. Submit first and final drafts.

No we have not yet worked on the Action Plan.

Yes first draft has been submitted.

Yes final draft has been submitted.

Yes we are implementing the Action Plan.

Comments about the Action Plan:

What has been the greatest challenge for you in working with your mentee during this past week?

Providing services (can't locate services or can't identify what is needed)

Mentee's attitude (resistant manipulative negative)

Mentee's progress (overwhelming issues self-destructive regressing)

Mentee is approaching challenges appropriately

Comments about these challenges:

When is your next meeting with your mentee scheduled? Mentors should meet with mentees 1-2 hours weekly at a consistent time. Always confirm the time and day of next meeting.

Is there a critical date coming up for your mentee in the next two months such as a court hearing graduation move divorce etc.?

Yes

No

If yes will you as a mentor be involved?

Yes

No

Please describe. Include event date location and significance:

Will you be out of town for a significant period of time soon?

Yes

No

If so dates:

Please explain your plan for supporting your mentee while you will be out of town.

How much time did you spend with your mentor advisor this week?

0 hours

Less than 1 hour

1 hour

2 hours

During the last week has your mentor advisor met all your needs? Please describe.

Comments: Please make sure to comment if you did not receive the support you needed.

Would you like to remain working with this particular client?

Yes

No

I'd like to talk about it

Journal Entry: Any material anecdotes and assessments are particularly helpful.

Do not enter anything in this field: