Mentee Application Form

1
Type
Mentor
Mentee
Volunteer/Sub-Contractor/Staff
Community Group/Support Org
Supporter
2
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
7
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
12
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
Surname
15
Preferred name (optional)
16
Date of Birth* This field is required.
Date of Birth
Day
Month
Year
17
Are you homeless?
Yes
No
18
Email address* This field is required.
example@example.com
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Mobile Phone Number* This field is required.
20
Address
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.
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Other
Even if homeless, which state are you currently residing?
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To help us direct your application, please tell us which Local Government Area you reside in* This field is required.
Please Select
Please Select
Adelaide
Adelaide Hills
Adelaide Plains
Albany
Albury
Alexandrina
Alice Springs
Alpine
Anangu Pitjantjatjara Yunkunytjatjara
Ararat
Armadale
Armidale
Ashburton
Augusta Margaret River
Aurukun
Ballarat
Ballina
Balonne
Balranald
Banana
Banyule
Barcaldine
Barcoo
Barkly
Barossa
Barunga West
Bass Coast
Bassendean
Bathurst
Baw Baw
Bayside (NSW)
Bayside (VIC)
Bayswater
Bega Valley
Bellingen
Belmont
Belyuen
Benalla
Berri Barmera
Berrigan
Beverley
Blackall Tambo
Blacktown
Bland
Blayney
Blue Mountains
Boddington
Bogan
Boroondara
Boulia
Bourke
Boyup Brook
Break O'Day
Brewarrina
Bridgetown-Greenbushes
Brighton
Brimbank
Brisbane
Broken Hill
Brookton
Broome
Broomehill-Tambellup
Bruce Rock
Bulloo
Buloke
Bunbury
Bundaberg
Burdekin
Burke
Burnie
Burnside
Burwood
Busselton
Byron
Cabonne
Cairns
Cambridge
Camden
Campaspe
Campbelltown (NSW)
Campbelltown (SA)
Canada Bay
Canning
Canterbury-Bankstown
Capel
Cardinia
Carnamah
Carnarvon
Carpentaria
Carrathool
Casey
Cassowary Coast
Ceduna
Central Coast (NSW)
Central Coast (TAS)
Central Darling
Central Desert
Central Goldfields
Central Highlands (QLD)
Central Highlands (TAS)
Cessnock
Chapman Valley
Charles Sturt
Charters Towers
Cherbourg
Chittering
Christmas Island
Circular Head
Clare and Gilbert Valleys
Claremont
Clarence
Clarence Valley
Cleve
Cloncurry
Cobar
Cockburn
Cocos Islands
Coffs Harbour
Colac Otway
Collie
Coober Pedy
Cook
Coolamon
Coolgardie
Coomalie
Coonamble
Coorong
Coorow
Cootamundra-Gundagai
Copper Coast
Corangamite
Corrigin
Cottesloe
Cowra
Cranbrook
Croydon
Cuballing
Cue
Cumberland
Cunderdin
Dalwallinu
Dandaragan
Dardanup
Darebin
Darwin
Darwin Waterfront Precinct
Denmark
Derby-West Kimberley
Derwent Valley
Devonport
Diamantina
Donnybrook-Balingup
Doomadgee
Dorset
Douglas
Dowerin
Dubbo
Dumbleyung
Dundas
Dungog
East Arnhem
East Fremantle
East Gippsland
East Pilbara
Edward River
Elliston
Esperance
Etheridge
Eurobodalla
Exmouth
Fairfield
Federation
Flinders (QLD)
Flinders (TAS)
Flinders Ranges
Forbes
Franklin Harbour
Frankston
Fraser Coast
Fremantle
Gannawarra
Gawler
George Town
Georges River
Gilgandra
Gingin
Gladstone
Glamorgan-Spring Bay
Glen Eira
Glen Innes Severn
Glenelg
Glenorchy
Gnowangerup
Gold Coast
Golden Plains
Goomalling
Goondiwindi
Gosnells
Goulburn Mulwaree
Goyder
Grant
Greater Bendigo
Greater Dandenong
Greater Geelong
Greater Geraldton
Greater Hume
Greater Shepparton
Griffith
Gunnedah
Gwydir
Gympie
Halls Creek
Harvey
Hawkesbury
Hay
Hepburn
Hilltops
Hinchinbrook
Hindmarsh
Hobart
Hobsons Bay
Holdfast Bay
Hope Vale
Hornsby
Horsham
Hume
Hunters Hill
Huon Valley
Indigo
Inner West
Inverell
Ipswich
Irwin
Isaac
Jerramungup
Joondalup
Junee
Kalamunda
Kalgoorlie-Boulder
Kangaroo Island
Karoonda East Murray
Karratha
Katanning
Katherine
Kellerberrin
Kempsey
Kent
Kentish
Kiama
Kimba
King Island
Kingborough
Kingston (SA)
Kingston (VIC)
Knox
Kojonup
Kondinin
Koorda
Kowanyama
Kulin
Ku-ring-gai
Kwinana
Kyogle
Lachlan
Lake Grace
Lake Macquarie
Lane Cove
Latrobe (TAS)
Latrobe (VIC)
Launceston
Laverton
Leeton
Leonora
Light
Lismore
Litchfield
Lithgow
Liverpool
Liverpool Plains
Livingstone
Lockhart
Lockhart River
Lockyer Valley
Loddon
Logan
Longreach
Lower Eyre Peninsula
Loxton Waikerie
MacDonnell
Macedon Ranges
Mackay
Maitland
Mandurah
Manjimup
Manningham
Mansfield
Mapoon
Maralinga Tjarutja
Maranoa
Mareeba
Maribyrnong
Marion
Maroondah
McKinlay
Meander Valley
Meekatharra
Melbourne
Melton
Melville
Menzies
Merredin
Mid Murray
Mid-Coast
Mid-Western
Mildura
Mingenew
Mitcham
Mitchell
Moira
Monash
Moonee Valley
Moora
Moorabool
Morawa
Moree Plains
Moreland
Moreton Bay
Mornington
Mornington Peninsula
Mosman
Mosman Park
Mount Alexander
Mount Barker
Mount Gambier
Mount Isa
Mount Magnet
Mount Marshall
Mount Remarkable
Moyne
Mukinbudin
Mundaring
Murchison
Murray
Murray Bridge
Murray River
Murrindindi
Murrumbidgee
Murweh
Muswellbrook
Nambucca Valley
Nannup
Napranum
Naracoorte Lucindale
Narembeen
Narrabri
Narrandera
Narrogin
Narromine
Nedlands
Newcastle
Ngaanyatjarraku
Nillumbik
No usual address (OT)
Noosa
North Burnett
North Sydney
Northam
Northampton
Northern Areas
Northern Beaches
Northern Grampians
Northern Midlands
Northern Peninsula Area
Norwood Payneham and St Peters
Nungarin
Oberon
Onkaparinga
Orange
Orroroo Carrieton
Outside Australia
Palm Island
Palmerston
Parkes
Paroo
Parramatta
Penrith
Peppermint Grove
Perenjori
Perth
Peterborough
Pingelly
Plantagenet
Playford
Pormpuraaw
Port Adelaide Enfield
Port Augusta
Port Hedland
Port Lincoln
Port Macquarie-Hastings
Port Phillip
Port Pirie
Port Stephens
Prospect
Pyrenees
Quairading
Queanbeyan-Palerang
Queenscliffe
Quilpie
Randwick
Ravensthorpe
Redland
Renmark Paringa
Richmond
Richmond Valley
Robe
Rockhampton
Rockingham
Roper Gulf
Roxby Downs
Ryde
Salisbury
Sandstone
Scenic Rim
Serpentine-Jarrahdale
Shark Bay
Shellharbour
Shoalhaven
Singleton
Snowy Monaro
Snowy Valleys
Somerset
Sorell
South Burnett
South Gippsland
South Perth
Southern Downs
Southern Grampians
Southern Mallee
Southern Midlands
Stirling
Stonnington
Strathbogie
Strathfield
Streaky Bay
Subiaco
Sunshine Coast
Surf Coast
Sutherland
Swan
Swan Hill
Sydney
Tablelands
Tammin
Tamworth
Tasman
Tatiara
Tea Tree Gully
Temora
Tenterfield
The Hills
Three Springs
Tiwi Islands
Toodyay
Toowoomba
Torres
Torres Strait Island
Townsville
Towong
Trayning
Tumby Bay
Tweed
Unincorp. Other Territories
Unley
Upper Gascoyne
Upper Hunter
Upper Lachlan
Uralla
Victor Harbor
Victoria Daly
Victoria Park
Victoria Plains
Vincent
Wagait
Wagga Wagga
Wagin
Wakefield
Walcha
Walgett
Walkerville
Wandering
Wangaratta
Wanneroo
Waratah-Wynyard
Waroona
Warren
Warrnambool
Warrumbungle
Wattle Range
Waverley
Weddin
Weipa
Wellington
Wentworth
West Arnhem
West Arthur
West Coast
West Daly
West Tamar
West Torrens
West Wimmera
Western Downs
Westonia
Whitehorse
Whitsunday
Whittlesea
Whyalla
Wickepin
Williams
Willoughby
Wiluna
Wingecarribee
Winton
Wodonga
Wollondilly
Wollongong
Wongan-Ballidu
Woodanilling
Woollahra
Woorabinda
Wudinna
Wujal Wujal
Wyalkatchem
Wyndham
Wyndham-East Kimberley
Yalgoo
Yankalilla
Yarra
Yarra Ranges
Yarrabah
Yarriambiack
Yass Valley
Yilgarn
York
Yorke Peninsula
Eg. Ballina, Broome, Liverpool, Bayside (VIC)
23
What led you to enquire with Mentoring Men?* This field is required.
24
Are there any specific goals you would like to work towards?* This field is required.
25
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.
Low Self Confidence
Loneliness or challenges making friends
Lack of purpose/meaning/direction in life
Procrastination, lack of discipline or motivation
Feeling Anxious
Feeling Depressed
Grief
Career Change/Unemployment/Redundancy
Finding success in work or career
Overcoming financial issues
Significant relationship breakdown
Understanding gender or sexual Identity
Fatherhood or raising children
Absence of a father figure
Acting as a father figure
Addiction and/or Recovery
Caring for people with disability or Illness
Living with diagnosed mental health conditions
Experience living with complex trauma including childhood trauma
Living with chronic pain or sickness
Experiencing racial inequality
Other (please share summary details)
26
Are there any additional comments you would like to share?
27
How did you hear about Mentoring Men?* This field is required.
Facebook
Instagram
LinkedIn
YouTube
Family or Friend
Website
Referring Agency
Related Organisation
Community radio/newspaper
Community Event
Job/Volunteer Ad
Employer
Western Sydney University
Other
28
Do you have an emergency contact person? * This field is required.
YESNO
29
Emergency Contact Full Name
30
Emergency Contact Relationship
31
Emergency Contact Mobile Phone Number
32
Are you ready to book your Intake Assessment?* This field is required.Your journey towards finding the right mentor is important to us. To move forward, the next step is to schedule your Intake Assessment. This chat is a crucial part of the process, where we'll discuss your eligibility and match you with one of our mentors.
I'm ready. Lets book my assessment. Tell me more about the Assessment Process.
33
The Intake Assessment Process: Getting to Know YouAt Mentoring Men, we focus on finding the right match for each mentee to ensure a successful and supportive mentoring relationship. As part of the intake process, we begin by learning more about who you are. This includes asking about your cultural background, gender identity, and whether you identify as part of the LGBTQIA+ community. We want to ensure that we respect and celebrate the diversity of all participants.
I understand
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The Intake Assessment Process: Your Goals and Well-BeingWe also ask about your personal goals and the reasons why you’re seeking a mentor. Whether you're looking to overcome challenges, develop new skills, or simply find understanding, this information helps us know how to support you. Additionally, we ask a few questions related to how often you experience feelings of loneliness, as it gives us a better understanding of how we can best support you.
I understand
35
The Intake Assessment Process: Matching PreferencesTo ensure the right mentor match, we consider any preferences you may have. You can share your thoughts on the type of mentor you'd respond to best, including their background, interests, and the types of challenges you’d like help with. We'll also ask about your availability, how far you’re willing to travel for meetings, and whether you prefer to connect face-to-face or virtually.
I understand
36
The Intake Assessment Process: Interpersonal Skills and Next Steps* This field is required.Finally, we assess how you handle challenges, emotions, and boundaries. This helps us ensure you and your mentor can form a healthy, productive relationship. You’ll also have an opportunity to ask any questions you may have about the program before we proceed with matching you to the right mentor.
I'm ready. Lets book.I'm still not sure.
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