Mentor Interest Survey

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740.245.3051
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- Prevention
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- Step 1 of 3

Youth's Information

Name

First

Middle

Last

Please complete all of the following. This survey will help Field of Hope Mentoring Program know more about you and your interests and help us find a good match for you.

What are the most convenient times for you to meet with your mentee? Please check all that apply.

Lunchtime
After School
Evenings
Weekends
Other

If "other" is checked above, explain:

Please indicate age group(s) you are interested in working with:

11-14 years of age
15-18 years of age

Do you speak any languages other than English? If so, which languages?

Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be willing to work with.

What are some favorite things you like to do with other people?

What are your favorite subjects to read about?

What is your job and how did you choose this field?

What is one goal you have set for the future?

If you could learn something new, what would it be?

What person do you most admire and why?

Describe your ideal Saturday.

Please check all activities you are interested in:

Animals/Pets
Biking
Boating
Board Games
Camping
Cooking
Fishing
Gardening
Golf
Hiking
Library
Movies
Music
Painting/Photos
Parks
Science
Shopping
Sports
Swimming
Yoga

List any other areas of strong interest:

Additional Information

The child is being referred for assistance in the following areas (check all that apply):

Academic Issues
Attitude
Behavioral Issues
Delinquency
Family Issues
Peer Relationships
Self-Esteem
Social Skills
Special Needs
Study Habits
Vocational Training
Other

Why do you feel this youth might benefit from a mentor?

What particular interests, either in school or out, do you know that the child has?

What strategies/learning models might be effective for a mentor working with this youth?

Youth Assessment

Academic Performance

Selected Value: 0

Social Skills

Selected Value: 0

Self-esteem

Selected Value: 0

Family Support

Selected Value: 0

Communication Skills

Selected Value: 0

Attitude About School/Education

Selected Value: 0

Peer Relations

Selected Value: 0

With what specific academic subjects, if any, does the student need assistance?

Additional Comments:

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