Contact Summary Form
To be completed by the RBTV Advisor after each engagement with an applicant. Note: Additional sections are to be completed if an essay or report card have been collected during the meeting.
Applicant Full Name
*
First Name
Last Name
RBTV Advisor
*
First Name
Last Name
If first meeting, indicate the best method to contact the Applicant and the Applicant's Parent/Guardian.
Home Phone
Mobile Phone
E-mail
Date/Time of this meeting or receipt of document:
*
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Month
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Day
Year
Date Picker Icon
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2
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4
5
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Method
In-person
Phone Call
Video Chat
Other
Who was present for the meeting?
Highlights of topics covered by RBTV Advisor
Highlights of topics dicussed by Applicant:
What was the level of the Applicant's participation?
Actively participated in the conversation by answering questions fully and asking questions
Answered all questions but asked few or no questions
Asked questions but did not provide full answers to questions asked
Did not actively participate
How do you think the meeting went?
1
2
3
4
5
Difficult
Very Well
1 is Difficult, 5 is Very Well
Scores of "1" require comment:
What is your impression of the Applicant to date?
Are there any family dynamics that RBTV should be aware of?
Follow-up items or topics for the next meeting:
School/Report Card (when collected)
If discussed or available via report card, please provide notes related to applicant's school attendance:
If discussed or available via report card, please provide notes related to applicant's conduct at school:
If discussed or available via report card, please provide notes related to the applicant's homework timeliness/ completion:
Does the applicant have an IEP or 504 plan in place at school? (if yes, please request a copy)
Yes
No
Are there other notes related to school that would be helpful for RBTV to know? Teacher comments, history of being bullied/bullying, etc.
Physical Health/Mental Health
Does the applicant have any current/past medical issues or treatment that RBTV should be aware of?
Does the applicant have any current/past mental health issues or treatment that RBTV should be aware of?
Essay (when submitted)
Topic
Reflect understanding of the topic:
Yes
No
Submitted on time? If not, provide explanation:
Level of Effort
1
2
3
4
5
Min
Max
1 is Min, 5 is Max
Your assessment
Date/Time of next meeting:
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Month
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Day
Year
Date Picker Icon
1
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4
5
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: