Mentor Monthly Report

Due by the first (1st) of the month for previous 15th through 15th period.)

Mentor Information:

Case Manager:

Mentor Full Name:
Phone Number:
Street Address:
City, State, Zip:
Cadet Name:
Phone Number:
Street Address:
City, State, Zip:

Type of Contact:

Did you have at least 4 hours of contact with your Cadet? Yes No

Date Specify Type (i.e. Email, Face-to-Face)

Post Residential Placement Activity:

Please check all boxes that best describes what your Cadet has been doing during the reporting month.Please write the dates that he/she enrolled in school, enlisted in a military service/shipped, or began working including employer’s name and wage amount.

Education Military Service Miscellaneous
Return to HS Active Reserve
Care Giver
Vo Tech Army
College Navy
Job Corps Marines
Adult Education Air Force
Moved Out-of-State
Coast Guard
National Guard
Enroll Date: Enlist Date:
School: Ship Date:
Counselor: MOS:


Hire Date Company Position Wage
Part Time
Full Time
Supervisor Name and Phone:
Termination Date:


Additional Information:

If your Cadet has made changes to his or her P-RAP (Post-Residential Action Plan), please provide the following information: Specific changes to the P-RAP; The Cadet’s expected outcome as a result of the changes; Why the Cadet made the changes; The mentor’s position and rationale regarding the changes?