Mentee Application
Trans Peer Mentor Program
Name
Pronouns
Date
-
Month
-
Day
Year
Date
Email address
example@example.com
Cell phone number
Please enter a valid phone number.
Address (#, City, State, Zip)
Parent / Guardian Name (if under 18)
Parent / Guardian Phone (if under 18)
Please enter a valid phone number.
Parent / Guardian Email (if under 18)
example@example.com
The Trans Peer Mentor Program is based in Oakland, CA but accepts mentees from elsewhere for virtual pairings. Are you able to meet your mentor in Oakland? (yes or no)
Gender Identity
Sexual Orientation
Ethnicity
Birth Date
/
Month
/
Day
Year
Date
Age
Religion/Spirituality
Hobbies
Other Identities you'd like to share
What gender were you assigned at birth?
Do you currently see a mental health professional?
If you're local to the Bay Area, what transportation will you use (car, public transportation, ride)
Accessibility needs (stairs alternative, scent free, etc)
Any additional information you'd like to share
How did you hear about the Trans Peer Mentor Program?
Why do you want to be paired with a mentor?
What topics regarding social transition are you curious about?
Chosen Name
Chosen Pronouns
Legal Name Change
Legal Gender Marker Change
Bathroom Use
STP's
Style/presentation
"Coming Out"
Choosing not to "come out"or be visible
Uncertainty around decisions
Other
What topics regarding medical transition are you curious about?
Bottom Surgery
Top Surgery
Hormone Replacement Therapy
Voice Training
Hair Removal
Detransitioning
Stopping Hormones
Choosing not to pursue medical changes
Uncertainty around particular medical changes
Other
What are some things you struggle with or have struggled with in the past that are unrelated to gender? This information is helpful when pairing you with a mentor.
Do you have any special requests regarding the identities or experiences of your mentor?
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