SENECA MENTORING YOUTH LINKS
For mentors and families involved in SMYL's traditional one on one mentoring program please take approximately 5-10 minutes to complete the following form.
Sign in to Google to save your progress. Learn more
Mentor/Parent Report on Match (Matches 6 months or more)
Definitions of questions, to refer to, are at the end of the Survey
Mentor Name *
Parent Name *
Are you the Mentor or Parent? *
Indicate the number of months that the match has been together. *
How would you describe any changes in the following areas within the match
CONFIDENCE
Section 1
1. Self-confidence *
2. Ability to express feelings *
3. Ability to make decisions independently *
4. Has interest or hobbies *
5. Personal hygiene, appearance *
6. Sense of the future *
COMPETENCE
Section 2
7. Attitude toward school *
8. Uses school resources *
9. Uses community resources *
10. School performance *
11. Able to avoid delinquency *
12. Able to avoid substance abuse *
13. Able to avoid early parenting *
CARING
Section 3
14. Shows trust toward you *
15. Respects other cultures *
16. Relationship with family *
17. Relationship with peers *
18. Relationship with other adults *
COMMENTS
DEFINITIONS
Instructions: The following definitions are offered to clarify the items on the retrospective Report on the Match form. Note that these items are somewhat general. This encourages the reporting person to “fill in” his or her own specific observations within the general context of these definitions. Any questions should be referred to the case manager.


GOAL AREA #1: SELF-CONFIDENCE

1. Self-confidence - A sense of being able to do or accomplish something.
2. Able to express feelings - Is able to reveal, talk about, or discuss feelings.
3. Can make decisions - Thinks before acting and is aware of consequences of behavior.
4. Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc.
5. Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean.
6. Sense of the future -- Knows about educational and career opportunities.


GOAL AREA #2: SOCIAL COMPETENCE

7. Attitude toward school - Is positive about going to school and about what can be learned in school
8. Uses school resources - Uses the library, guidance counselors, tutorial centers.
9. Uses community resources - Partakes in service activities, libraries, recreation, church/other faith-based activities.
10. School performance - Makes good grades or improves grades.
11. Able to avoid delinquency - Refrains from behaviors that are illegal for person of his other age.
12. Able to avoid substance abuse - Doesn’t use illegal or harmful substances (ex. drugs, alcohol, tobacco, etc.).
13. Able to avoid early parenting - Doesn’t engage in sexual behavior likely to result in early parenting.


GOAL AREA #3: CARING

14. Shows trust toward you - Isn’t reluctant to confide in you, to accept your suggestions.
15. Respects other cultures - Doesn’t stereotype or put down other ethnic, racial, language, or national groups.
16. Relationship with family - interacts well with other family members.
17. Relationship with peers - interacts well with persons of own age.
18. Relationship with other adults - Has good interactions with other adults who are not family members.

Copyright @ 1998 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document with acknowledgement of Big Brothers Big Sisters of America.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of NCOESC. Report Abuse
Google Forms