R&R BecomingHIM™ Mentee Intake & Needs Assessment
Share a few details about you and the support you want so R&R can plan services and make a good mentor match—parent/guardian involvement comes before mentoring begins.
About You
Full Name
*
First Name
Last Name
Preferred Name / Nickname
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Grade
*
Please Select
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Other
School
City / County
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Relationship to Youth
*
Please Select
Mother
Father
Stepparent
Grandparent
Aunt/Uncle
Legal Guardian
Foster Parent
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Either Phone or Email
About Me
What are your interests or hobbies?
Sports
Gaming
Music
Art
Reading
Technology
Outdoors
Faith/Church
Volunteering/Community Service
Other
What activities are you currently involved in?
What are three things you are good at?
What is one thing you would like to get better at?
What do you hope to do after high school?
Please Select
Go to college or university
Attend trade or technical school
Join the workforce
Military service
Start a business
Take a gap year
Not sure yet
Other
What careers are you interested in, if any?
What I Want From a Mentor
Reasons for wanting a mentor
*
Someone to talk to
School support
Career guidance
Confidence/self-esteem
Decision-making
Friendships/relationships
Anger/conflict management
Accountability
Life skills
Financial skills
Sports/activities
Faith/spiritual growth
Positive male role model
Other
Top three areas where you want the most support
What qualities do you want in a mentor?
How often would you like to meet?
*
Weekly
Twice monthly
Monthly
Unsure
Preferred meeting style
*
In-person
Group activities
Phone/video check-ins
Combination
Current Needs/Barriers
What kinds of support do you need right now?
School/academic support
Transportation
Food/basic needs
Clothing
Technology/internet
Healthcare/dental
Mental/emotional wellness resources
Family support
Extracurricular/activity costs
Job/career help
Financial/life-skills education
Other
Is there anything happening right now that you would like R&R to know so we can better support you? You do not have to share anything you are uncomfortable sharing.
Safety/Support
Trusted Adult Name
*
First Name
Middle Name
Last Name
Relationship to You
*
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Goals
One goal for the next 3 months
*
One goal for the next year
*
What would make you say having a mentor was helpful?
*
Final
Anything else you want us to know about you?
Submit
Should be Empty: