Mentor Exit Survey "*" indicates required fields Today's Date* MM slash DD slash YYYY Your Name:* First Last Client's Name:* First Last Client's Email*ConceptualizationPrimary Concerns* Anxiety Depression Psychosis Eating Difficulties Substance Use Struggles Pornography Use Trauma Identity & Self-Esteem Issues Relational Difficulties Personality Defenses Adjustment-Related Issues Please select any that apply to your client.Personality Organization / Defenses Observed* Antisocial / Psychopathic Avoidant Borderline Histrionic Dependent Depressive and Manic Masochistic / Self-Defeating Narcissistic Obsessive and Compulsive Paranoid Passive Aggressive Schizoid Check all that apply.How would you rate their ability to engage in self-reflection?* Excellent Good Fair Very Limited Poor Goals & ProgressHow long did mentorship last?* Less than One Month One Month One -Three months. Three-Six months. Six Months-One year. More than a Year. What was the average length of messages exchanged?* 15 minutes or more 10-15 minutes 5-10 minutes Under 5 minutes They Did Not Engage How often did your client engage in mentorship?* Every Day Five or Six Days a Week Three or Four Days a Week Once or Twice a Week They Did Not Engage Please Describe the Mentorship Relationship.*Feel free to include any noteworthy dynamics. For example: was the client extremely consistent or sporadic in how they engaged.Did the client meet their goals?* Yes No Sad to hear that they did not meet their goals. What do you think got in the way?*How satisfied do you think your client was with mentorship?* Very Satisfied Satisfied Neutral Unsatisfied Δ
