Example Final Leadership Counselor and Mentor Assessment Form

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This form was built to allow leadership counselors and mentors to reflect on their role and to identify places where they could improve halfway through the program, as well as give feedback to what could help them more in the role.

Name and Rank: *

What is your role in the program?

Leadership Counselor

Mentor

Other

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What helped you in your role?

What hindered you in your role?

What is your relationship with other leaders in the program like?

Please rank your overall satisfaction with your own performance, with 1 being highly unsatisfactory and 10 being highly satisfactory.

Highly Unsatisfactory

Highly Satisfactory

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If you ranked yourself in unsatisfactory range (at 5 or below), please explain:

If you ranked yourself in satisfactory range (at 6 or above), please explain:

Please rank your overall satisfaction with the program, with 1 being highly unsatisfactory and 10 being highly satisfactory.

Highly Unsatisfactory

Highly Satisfactory

Clear selection

If you ranked the program in unsatisfactory range (at 5 or below), please explain:

If you ranked the program satisfactory range (at 6 or above), please explain:

Would you recommend this program? Why or why not?

Is there anything this survey didn't ask that you want us to know?

Thank you for your time!

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