Survey - Prisoners or Patients: Individual Session Form

Field Is Required Participant Name

Field Is Required Mentor Name

Field Is Required Date of Conversation

Field Is Required Conversation Initiated By

Field Is Required Type of conversation

Length of Conversation

Any changes in contact information?

Please list changes to contact information here. (Maximum response 255 chars, approx. 5 rows of text)

Goals Addressed/Progress Made:

Use the following Rating Scale after reviewing previous meeting notes.

1 - Set Back

2 - No Change

3 - Some Progress

4 - Significant Progress

5 - Goal Attained

Use the scale along with a brief narrative as to the reason for that rating. (Maximum response 255 chars, approx. 5 rows of text)

New Challenges to Address:

Re-offending/ mental health issues/ loss of housing/ loss of employment, etc (Maximum response 255 chars, approx. 5 rows of text)

Any Coordination of Care Release Forms Requested? (Maximum response 255 chars, approx. 5 rows of text)

Recommendations/Shared Goals:

Participant agrees to: (Maximum response 255 chars, approx. 5 rows of text)

Participant hesitant to: (Maximum response 255 chars, approx. 5 rows of text)

Participant opposes: (Maximum response 255 chars, approx. 5 rows of text)

Is this program helpful to you in achieving your goals?

Next Steps: (Maximum response 255 chars, approx. 5 rows of text)

Summary of Session by Mentor/ Describe Session: (Maximum response 255 chars, approx. 5 rows of text)