Mentorship Documentation Form Page 2

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___ Direct Observation of Same Discipline for three IFSP Annual 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 one Transition Conference meeting
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Observation of Same Discipline for 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 Observation of 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 observations
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: ____________________________________________________
Mentorship Performance/Participation Requirements
(under the direct supervision of mentor)
___ Performance of three multi-disciplinary Eligibility Evaluations
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Performance of 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 Participation in three Initial IFSP meetings
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
___ Direct Participation in three IFSP Periodic Review meetings
1. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
2. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
3. Date: ____________
Location: ___________________________________
Mentor’s Signature: _______________________________
Page 2 of 3
Revised 10/11

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