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This is only a SAMPLE of what the real survey will look like. Please do NOT distribute this version of the survey to constituents of your program.

If you are interested in using the Vermont Mentoring Surveys for your program, please email benji@mobiusmentors.org to receive your unique survey links.

[Program Name/Info Here]

Question Title

* Mentee ID Number:

Question Title

* This youth is able to make and keep friends easily.

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* This youth has positive conflict resolution skills.

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* This youth is helpful.

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* This youth tends to bounce back quickly after hard times.

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* When something is bothering this youth, he/she seeks support.

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* This youth is hopeful about his/her future.

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* This youth believes that what he/she does now will not affect their future.

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* This youth likes going to school.

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* This youth cares about how he/she does in school.

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* This youth has positive relationships with teachers and other adults in the school.

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* This youth pays attention in school.

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* I have noticed positive changes in this youth since he/she started being mentored.

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* I would recommend having a mentor for other students I work with.

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* In the last four weeks, how many days was this student absent from school?

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* How far do you think THIS YOUTH THINKS he/she will go in school?

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