Mentorship Application Form

THE COUNSELING BROTHERS OF ATLANTA MENTORSHIP Application

For Black Male Master-Level Mental Health Students
Personal Information
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cellular Number
E-mail
example@example.com
Work Number
Education Information
Name of University/Institutution
Current Academic Year
Major/Area of Study
Current GPA
Expected Graduation Date
Professional Experience
Relevant Internship, Practicums, or Work Experience
Why are you interested in joining The Counseling Brothers of Atlanta mentorship program?
What unique qualities or experiences do you bring to this program that distinguishes you from other applicants?
In the context of your professional journey, can you articulate the key milestones or objectives you aim to achieve over the next 3-5 years? How do you believe mentorship can help you reach these goals?
References
Please provide 1 professional or academic reference who can speak to your dedication, character, and fit for this mentorship program:
Terms and Agreement:

By signing below, I affirm that all information provided on this application is accurate to the best of my knowledge. I understand that any misrepresentation or false statement could result in the rejection of my application or immediate termination from The Counseling Brothers of Atlanta mentorship program.
Date of Signature*

MonthDayYear
Date
Signature*

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Thank you for your interest in The Counseling Brothers of Atlanta, Inc. Mentorship Program. We are dedicated to fostering the next generation of Black male mental health professionals and are excited about the possibility of working with you.
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THE COUNSELING BROTHERS OF ATLANTA MENTORSHIP Application

Personal Information

Education Information

Professional Experience

References

Terms and Agreement:

Thank you for your interest in The Counseling Brothers of Atlanta, Inc. Mentorship Program. We are dedicated to fostering the next generation of Black male mental health professionals and are excited about the possibility of working with you.