Mentorship Documentation Form Page 3
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3___ Direct Participation in three IFSP Annual meetings
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Participation in one Transition Conference meeting
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Performance of three Sessions in the Child/Family’s Everyday Routines and Places (one session must be in a site other than the family
home)
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Participation in three joint visits in the Child/Family’s Everyday Routines and Places each with a different licensed healing arts
professional (FOR ITDS ONLY)
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Documentation of six (6) debriefing/critique/discussion meetings with Mentor on performance
1.
Date: ________
Mentor’s Signature: ____________________________________________________
2.
Date: ________
Mentor’s Signature: ____________________________________________________
3.
Date: _______
Mentor’s Signature: ____________________________________________________
4.
Date: ________
Mentor’s Signature: ____________________________________________________
5.
Date: ________
Mentor’s Signature: ____________________________________________________
6.
Date: ________
Mentor’s Signature: ____________________________________________________
Comments by Mentee:
Comments by Mentor:
Mentorship Completion Date: _____________________
Signature of Mentee: ___________________________________
Date: __________________
Signature of Mentor: _____________________________________
Date: __________________
Submitted to Early Steps Enrollment Specialist by: __________________________ Date: ___________________
Page 3 of 3
Revised 10/11
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