Mentor Visit Record
Mentor Name
Resident Name
Visit Date
-
Month
-
Day
Year
Date
Time In
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time Out
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Visit Details
What Independent Living Activities Were Addressed this Visit? (Select All)
Cooking and Meal Preparation
Money Management
Time Management
Personal Hygiene and Self-Care
Communication Skills
Job Search & Interviewing
Grocery Shopping
Public Speaking and Presentation Skills
Social Etiquette
Critical Thinking & Problem Solving
Civic Responsibilities
Basic First Aid and Health Knowledge
Household Chores
Other
Describe additional details of the visit
Describe the child's attitude during the visit
Strengths Observed During Visit
Concerns Identified
Do you have any concerns regarding today's visit?
No
Yes
If yes, list concerns:
Signature
I am hereby submitting my electronic signature for this visit record and attest the information contained herein is accurate and true.
Submit
Should be Empty: