Discovering Options, Delivering Innovative Social Services

mentor journal

Please complete the Mentor Journal for one month (i.e. January) at a time. When marking the dates you have seen your Protege, select the month and one or more days of that month. (Selecting more than one month at a time, will create an error.) Once the information for that month is complete, click "Submit Form" at the bottom of the page. Thank you!

Mentor Name:

Protege Name:

Please mark the dates that you have seen your protege.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

18 19 20 21 22 23 24 25 26 27 28 29 30 31

What did you do together this month?

Cooked
Went to my house
St Loiuis Zoo
Out to lunch
Running errands
Homework
Movies

Library
Science center
Out to dinner
Shopping
Picnics
Live theater
Other

How would you rate your relationship this month?

Thumbs Up
Thumbs Sideways
Thumbs Down

Did you provide your protege and or their family with any material goods, money or referrals this month?

Yes
No

If yes, what?

Clothes
Appliances
Tuition at a camp or other program
Other Item

School supplies
Camp supplies
Bus passess

Did your protege initiate contact with you this month?

Yes
No

If yes, how many times?

1
2
3
4
5 or More

Are you frustrated with your relationship with your protege?

Yes
No

Including this outing, how many have you completed?

+20