Mentee Application Form

1
Type
Mentor
Mentee
Volunteer/Sub-Contractor/Staff
Community Group/Support Org
Supporter
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Mentoring Men is not a crisis service. If you or someone you know is in need are in crisis or an emergency, please call '000' or Lifeline on 131114* This field is required.
I Understand
3
Are you seeking support for yourself?* This field is required.
Yes
No
4
Is the person you are seeking support aware you are contacting us?* This field is required.
Yes
No
5
Does the person seeking support agree for Mentoring Men to contact them directly* This field is required.
Yes
No
6
What is your relationship to the person seeking support?* This field is required.
Family
Friend
Referral Agency
Spouse/former spouse
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What is the name of the agency who is refering the person seeking support?* This field is required.
8
What is the name of person completing this referral* This field is required.
9
What is the referring persons mobile number
Please note you will just need to enter the last 8 digits of your mobile number.
10
What is the referring persons email* This field is required.
example@example.com
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What is the name of person completing this referral* This field is required.
First Name
Last Name
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Family or Friend Mobile Number* This field is required.
Please note you will just need to enter the last 8 digits of your mobile number.
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Family or Friend Email Address* This field is required.
example@example.com
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Name* This field is required.
First Name
Last Name
15
Preferred First Name (optional)
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Date of Birth* This field is required.You must be 18+ years old. Knowing your age enables us to match you to the right mentor
Date of Birth
Day
Month
Year
17
Are you homeless?
Yes
No
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Email address* This field is required.We only support men who currently reside in Australia
example@example.com
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Mobile Phone Number* This field is required.We only support men who currently reside in Australia
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AddressWe only support men who currently reside in Australia
Street Address
Street Address Line 2
Suburb
State
Postal Code
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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State* This field is required.We only support men who currently reside in Australia
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Other
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What has led you to enquire about getting a personal mentor?* This field is required.Thanks for being up-front to explain
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What specific goals you would like to work towards, or challenges to overcome?* This field is required.Your mentor will need to understand which areas of life he can support you best
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Challenges and Growth: Carefully review this list below and select all that are applicable to you. Select the challenges you are facing, or the areas you wish to develop youself.* This field is required.
Lack of purpose/meaning/direction in life
Procrastination, lack of discipline or motivation
Caring for people with disability or Illness
Caring for a loved one with endo or pelvic pain
Career Change/Unemployment/Redundancy
Finding success in work, study
Adjusting to retirement
Feeling Anxious
Absence of a father figure/male role model
Significant relationship breakdown
Low Self Confidence
Loneliness or challenges making friends
Fatherhood or raising children
Understanding gender or sexual Identity
Addiction and/or recovery
Living with diagnosed mental health conditions
Living with chronic pain or sickness
Feeling Depressed
Living with trauma
Adjusting to local Australian culture
Experiencing racial inequality
Grief
Overcoming financial issues
Other
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Partner Programs* This field is required.
Please Select
Please Select
None
QENDO/Endometriosis Support
Casey Mens Forum
RSL LifeCare
26
Are there any additional comments you would like to share?
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How did you hear about Mentoring Men?* This field is required.Please choose ONE
Facebook
Instagram
LinkedIn
YouTube
Family or Friend
Website Search
Referring Agency or Professional
Related Organisation
TV, Radio, Newspaper
Event Stall
Job/Volunteer Ad
Employer
Partner Program
Podcast
Flyer or Poster
Other
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Do you have an emergency contact person? * This field is required.
YESNO
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Emergency Contact First & Last Name
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Emergency Contact Relationship to You
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Emergency Contact Mobile Number
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Are you ready to book your Intake Assessment?* This field is required.The next step is to schedule your Intake Assessment chat over a Teams video call or via phone (up to 45min) with one of our experienced volunteer mentors to check our program is a good fit for you. All being well, this call helps us ensure we find you a good mentor match, leading to the healthy, productive conversations that you're looking for. It's also your opportunity to ask any questions you may have about the program before we proceed with matching you to the right mentor. Remember mentoring is a 2-way street with solid, respectful commitments and open communication from both sides to make it work well. Some guys never get this far - you're already indicating you're ready to help yourself to a better future. Well done..!
I'm ready. Lets book the assessment chat (click NEXT) Tell me more about the assessment process.
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The Intake Assessment Process: Getting to Know YouAt Mentoring Men, we focus on finding the right match for each mentee (that's you!) to ensure a successful and supportive mentoring relationship with your mentor. As part of the intake process, we begin by learning more about who you are over a conversation. One of our experienced mentors will conduct the chat and with your input will be completing a form to gather that details we need help us find you the right mentor. These areas include asking about your cultural and diversity identity, any languages you feel comfortable speaking and if you have caring duties at home. We want to ensure that we respect and celebrate the diversity of all participants, and if you'd rather not answer any of them, that's OK.
I understand
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The Intake Assessment Process: Your Goals and Well-BeingWe'll expand a little on your personal goals and the reasons why you’re seeking a mentor. It's always good to hear it in your own words. Whether you're looking to overcome specific challenges or simply find clarity, this information helps us and your future mentor to know how to support you, and for both of you to focus on the direction that your conversations need to take.
I understand
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The Intake Assessment Process: Matching PreferencesTo ensure the right mentor match, we'll ask you about any preferences you may have. You can share your thoughts on the type of mentor you'd respond to best, including their life experience, and their personal communication style that you believe you need right now. We'll also ask about whether you're OK to connect virtually by video or phone, (this will widen the available mentor selection) or if you need to meet and talk together in person (finding a more local appropriate mentor may take a bit longer).
I understand
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The Intake Assessment Process: Any Final Questions? Next Steps* This field is required.The next step is to schedule your Intake Assessment chat over a Teams video call or via phone (up to 45min) with one of our experienced volunteer mentors to check our program is a good fit for you. All being well, this call helps us ensure we find you a good mentor match, leading to the healthy, productive conversations that you're looking for. It's also your opportunity to ask any questions you may have about the program before we proceed with matching you to the right mentor. Remember mentoring is a 2-way street with solid, respectful commitments and open communication from both sides to make it work well. Some guys never get this far - you're already indicating you're ready to help yourself to a better future. Well done..!
I'm ready. Lets book (click NEXT)I'm still not sure.
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