Women’s Mentoring Group Application & Intake Form

Women’s Mentoring Group Application & Intake Form

Share your goals, needs, strengths, and availability so we can review program fit and next steps. Applicants must be 21 years of age or older.
Women mentorship with Dr. Arleen A. Fuller, Dr. Soneisha Ling, Dr. Tonshay Rufus
Personal Information
Full Name

First NameMiddle NameLast Name
Preferred Name
Email Address
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Preferred Contact Method
Best Time to Contact

Hour Minutes

AM/PM Option
About You
Marital Status
Date of Birth

MonthDayYear
Date
Employment Status
Occupation or Business
Church or Faith Community
Children or Dependents
Please briefly describe yourself
Mentoring Goals
Why do you want to join this mentoring group?
Top three mentoring focus areas

Other
What do you hope to accomplish in the next 90 days?
What is your biggest current challenge?
What has prevented progress so far?
What strengths and gifts do you bring to the group?
What support do you need most right now?
Participation and Availability
Preferred meeting format
Preferred days for meetings
Preferred times for meetings
Can you attend regularly?
Are you willing to complete assignments and participate in group discussions?
Do you have access to the following?
Accessibility accommodations needed
Group Safety and Confidentiality
I agree to respect the privacy of other group members.
I agree to communicate respectfully with other group members and facilitators.
I agree not to record, photograph, screenshot, or share group discussions without permission.
I understand that mentoring is educational and supportive and is not a substitute for medical care, licensed psychotherapy, crisis intervention, or legal advice.
Emergency and Wellness Information
Emergency Contact Name

First NameLast Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything the mentor should know to support you safely?
Commitment
Readiness to begin now

1

2

3

4

5

6

7

8

9

10

1 is Not ready, 10 is Fully ready
Why I am ready now
What I am willing to commit to

Other
Signature and date confirming accuracy and acceptance of space and program fit
Optional Permissions
Permission to receive program emails
Permission to receive text messages
Media and testimonial permission

I do not consent
Should be Empty:

Women’s Mentoring Group Application & Intake Form

Women mentorship with Dr. Arleen A. Fuller, Dr. Soneisha Ling, Dr. Tonshay Rufus

Personal Information

About You

Mentoring Goals

Participation and Availability

Group Safety and Confidentiality

Emergency and Wellness Information

Commitment

Optional Permissions