Mentee Referral Form – Part B
Please answer the following questions as truthfully as possible. This application will only be seen by Trusted Mentors Staff. Trusted Mentors is an inclusive organization that strives to serve the needs of all residents of Marion County. We do acknowledge everyone's individual beliefs. We will make every effort to match according to your preferences.
Full Name
Mr.
Ms.
Mrs.
Dr.
Prof.
Rev.
Prefix
First Name
Middle Initial or Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Alternate Phone Number
Phone Preference
Call
Text
Email
example@example.com
Please name the Agency that you are working with.
*
If you have a case manager (or someone similar), please name them here.
Please provide your case managers phone number (if known)
-
Area Code
Phone Number
Please provide your case manager's email address (if known)
example@example.com
How do you Identify:
*
Man
Woman
Transman
Transwoman
Non-Binary
Other
Please indicate preferred Pronouns:
*
He/Him
She/Her
They/Them
He/They
She/They
Other
Are you comfortable interacting with the LGBTQIA+ community?
*
Yes
No
Other
Current Date
-
Month
-
Day
Year
Date
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Have you or a family member ever served in the military?
*
Yes
No
Primary Language
English
Spanish
Other
Other Languages Spoken:
Spanish
German
Haitian Creole
Other
Number of Children:
*
Ages of Children:
Children 18 and under?
Yes
No
Marital Status:
*
Single
Married
Divorced
Separated
Widowed
Domestic Partner
Common Law
Which best decribes you:
*
African American
Asian
Caucasian
Hispanic/Latino
Hawaiian / Pacific Islander
Native American
Multi-Racial
Other
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Choose 1 or 2 categories that best describes you:
*
Currently incarcerated (prison or work release)
Ex-Offender (released within the last 3 years)
Chronically Homeless; Low Income / Unemployed
Young Adult between 18 - 24 who has aged out of foster care
Young Adult between 18 - 24
Please explain your history of convictions (if applicable):
Were any of your convictions for a sex offense?
Yes
No
Do you have a history of: (check if true)
Addiction
Mental Illness
Domestic Violence
Please briefly explain your history with the above:
Which best describes you:
*
Currently Incarcerated (Prison or Work Release)
Ex-Offender (Released within the last 3 yrs)
Chronically Homeless Low Income/Unemployed
Young Adult between 18-24 who has aged out of foster care
Young Adult between 18-24
Education Level Completed
*
8th Grade or Less
9th - 11th Grade
HS Diploma
GED / HSE
Some College
Associates Degree
Bachelors Degree
Masters Degree
Doctoral Degree
Degree Major/Minor and Date:
Also list certifications or licenses
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What times are you most available?
*
Weekdays AM
Weekend AM
Weekdays PM
Weekend PM
Currently Employed?
*
Yes
No
Area of town where employed?
Do you have reliable transportation available?
*
Yes
No
Driver's license status?
*
Valid
Suspended
Expired
Never Licensed
Please Explain why you are interested in having a mentor and what you hope to gain:
*
What specific areas of life do you want to work on with your mentor? (max 4)
*
Personal Finance (e.g. budgeting from paycheck to paycheck)
Obtaining employment or improving employment
Improving level of Education
Improving homemaking skills (taking care of your home)
Establishing a network of reliable people
Childcare and parenting skills
Maintaining stable housing
Transitioning from recovery house into life
Transition from incarceration to the community
Transition from foster care to independent living
Completing the process of divorce
Helping to develop methods to prevent living in crisis
Why did you choose those specific areas to work on?
How would you briefly describe your personality or strengths?
*
What are you looking for in a mentor? What kind of person would you like to be mentored by?
*
Please rate your level of: (1 is low and 10 is high)
*
1
2
3
4
5
6
7
8
9
10
Self-Esteem
Social Skills
Family Support
Communication Skills
Peer Relationships
Motivation for Change
Is faith/spirituality an important part of your life?
*
Yes
No
Would you prefer a mentoring experience based on faith/spirituality?
*
Yes
No
Either
If yes, what is your Faith Tradition?
Buddhist
Catholic
Christian
Hindu
Jewish
Muslim
Other
How do you rate your motivation to achieve change?
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
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Activities and Hobbies
What are your interests? (Check Top 2-3 in each category)
GENERAL
Arts/Crafts
Dance
Movies
Reading
Shopping
Drama
Board Games
Pet
Cooking
Eating Out
Computer Games
TV
Fashion
Writing
Video Games
Travel
PLAYING SPORTS
Basketball
Golf
Martial Arts
Track/Field
Baseball
Gymnastics
Soccer
Volleyball
Cheerleading
Hockey
Softball
Wrestling
Football
Lacrosse
Tennis
Other
WATCHING SPORTS
Basketball
Golf
Martial Arts
Track/Field
Baseball
Gymnastics
Soccer
Volleyball
Cheerleading
Hockey
Softball
Wrestling
Football
Lacrosse
Tennis
Other
CULTURAL EVENTS
Theater
Concerts
Museums
Other
OUTDOOR ACTIVITIES
Biking
Ice Skating
Walking
Hiking
Boating/Canoeing
Rollerblading
Skiing
Running
Fishing/Hunting
Skateboarding
Snowboarding
Other
MUSIC
Listening to Music
Playing an Instrument
Singing
Other
ADDITIONAL COMMENTS / QUESTIONS
Please verify that you are human
*
Submit
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