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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@mentorvt.org to receive your unique survey links.

[Program Name/Info Here]

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* 1. Mentee ID Number:

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* 2. Mentee Age:

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

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* 4. If the youth gets in a disagreement with their friends, they are able to work it out.

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* 5. The youth is helpful.

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* 6. If something upsetting happens to the youth, they are able to get over it quickly.

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* 7. If something is bothering the youth, they seek support.

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* 8. The youth is hopeful about their future.

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* 9. The youth believes that what they do now will not affect their life as an adult.

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* 10. The youth likes going to school.

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* 11. The youth cares about how they do in school.

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

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* 13. The youth pays attention in school.

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* 14. I have noticed positive changes in this youth since they started being mentored.

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

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