Mentorship Documentation Form

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Early Steps
Mentorship Documentation Form
Mentee Information
Mentee Full Name: ______________________________ __________________________________ _____
SS#: _____ - ____ - ______
Please Print
Last
First
MI
Provider Type: ____ Licensed Healing Arts
____ Infant Toddler Developmental Specialist (ITDS)
____ Other (Specify) ______________
Address: ________________________________________________________________________________________________________________
Please Print
Street
City
State
Zip Code
Telephone: ________________________
Fax: ______________________
Email: __________________________________
Agency: __________________________________________________
Local Early Steps: ________________________________________
Date of Hire or Contract with Agency/LES: _________________________
Date Mentorship Initiated: __________________________
Mentor Information
Primary Mentor
_________________________________ ____________________________________ ____
ITDS -Mentor must be either a CMS enrolled
Last
First
MI
ITDS or a CMS enrolled EI Provider.
All others-Mentor must be same discipline as mentee.
Provider Type: ____ Licensed Healing Arts
____ Infant Toddler Developmental Specialist (ITDS)
____ Other (Specify) ______________
Address: ________________________________________________________________________________________________________________
Please Print
Street
City
State
Zip Code
Telephone: ________________________
Fax: ______________________
Email: __________________________________
Agency: __________________________________________________
Local Early Steps: ________________________________________
Mentorship Observation Requirements
(under the direct supervision of mentor)
___ Direct Observation of Same Discipline for three multi-disciplinary Eligibility Evaluations
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Observation of Same Discipline for three multi-disciplinary Assessments (may be the same as the Eligibility Evaluations if
conducted together)
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Observation of Same Discipline for three Initial IFSP meetings
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Observation of Same Discipline for three IFSP Periodic Review meetings
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
Page 1 of 3
Revised 10/11

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