Mobility Mentoring Referral Reference
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Prospective Participant Name: *
How long have you known the prospective participant and in what capacity do you know them? *
How long has it been since you have had contact with the prospective participant? *
The Mobility Mentoring model focuses on goal-setting and behavior change.Tell us about a time when the prospective participant set a goal and achieved or worked toward this goal. What was the behavior or life change that occurred as a result? *
Based on your experience with the prospective participant, does the prospective participant keep appointments and maintain contact with people she is working with? Please provide specific reasons for your answer. *
This partnership is at least two years long. Based on your experience with the prospective participant, do you believe that they can commit for at least that amount of time? Please provide specific reasons why or why not. *
Do you think they would be comfortable meeting new people and sharing some of their experiences in a community group setting? Why or why not? *
Please provide an example of a time when the prospective participant took a lot of initiative and engaged in self-directed activities. *
Do you think that they have the support system to help them on this journey? Why or why not? *
In your opinion, is the prospective participant open to feedback and/or guidance? Why or why not? *
Is there anything else you would like us to know about this prospective participant? *
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