IDDM Exit Survey

Unique ID

Name*

First Last

Email*

Today's Date*

Consent*

I understand this survey is for personal reflection and program improvement. It is not a clinical assessment or diagnosis. If I am experiencing significant distress, I understand I should reach out to a licensed mental health professional or emergency services.

I understand and consent to continue

Assigned Mentor*

Please select the mentor that you worked with.

Mentorship Start Date*

If you don't recall the exact start date, please estimate to the best of your ability.

Mentorship End Date*

If you don't recall the exact end date, please estimate to the best of your ability.

Expectations

What prompted you to seek mentorship?*

How stressed do you currently feel about your initial concerns?*

Not Stressed

Mildly Stressed

Moderately Stressed

Very Stressed

Extremely Stressed

What were your initial goals for mentorship?*

Did you meet your goals?*

Yes

We are happy to hear that you met your goals. What was most helpful?*

We are sad to hear that you did not meet your goals. Please provide us with some feedback.*

How long did your mentorship last?*

One month.

Three months.

Six months.

One year.

More than a Year.

What was the average length of the messages that you left for your mentor?*

15 minutes or more

10-15 minutes

5-10 minutes

Under 5 minutes

I did not engage.

How often did you engage in mentorship?*

Every day.

Five or Six Days a Week

Three or Four Days a Week

Once or Twice a Week

I did not engage.

To what extent was spirituality explored during mentorship?*

Well-Being Reflection

Take a moment to reflect on how you’ve been doing since concluding your mentorship journey—emotionally, relationally, and spiritually. This self-reflection includes three short questionnaires designed to offer insight into your well-being and areas of growth. Your responses will help you notice meaningful patterns and reflect on the progress you’ve made. This is not a medical diagnosis. If you are in crisis, feeling unsafe, or having thoughts of harming yourself, please contact a licensed mental health professional or emergency services immediately.

Part 1*

Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading or watching TV
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

Part 2*

Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it’s hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Part 3*

Below are five statements with which you may agree or disagree. For each of the five statements, mark the most appropriate box indicating how you have felt over the last two weeks. Please indicate for each of the five statements which is closest to how you have been feeling over the last two weeks:

	At no time	Some of the time	Less than half the time	More than half the time	Most of the time	All of the time
1. I have felt cheerful and in good spirits
2. I have felt calm and relaxed
3. I have felt active and vigorous
4. I woke up feeling fresh and rested
5. My daily life has been filled with things that interest me

Mentorship Experience Feedback

How satisfied were you with your mentorship experience?*

Very Satisfied

Satisfied

Neutral

Unsatisfied

How likely are you to recommend our mentorship program to someone else?*

Very Likely

Likely

Neutral

Unlikely

If someone you know was considering mentorship, what would you want them to know about the program?*

Please Provide Any Comments or Feedback:*

Exit Survey (OpsHub)

Expectations

Well-Being Reflection

Mentorship Experience Feedback