Mentee Referral

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. If you have questions, please reach out to Alex Richards - arichards@trustedmentors.org. Thanks!
Full Name

PrefixFirst NameMiddle Initial or NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Alternate Phone Number
Phone Preference

CallText
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 CodePhone Number
Please provide your case manager's email address (if known)
example@example.com
How do you Identify:*

ManWomanTransmanTranswomanNon-BinaryOther
Please indicate preferred Pronouns:*

He/HimShe/HerThey/ThemHe/TheyShe/TheyOther
Are you comfortable interacting with the LGBTQIA+ community?

YesNoOther
Current Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Age
Have you or a family member ever served in the military?*

YesNo
Primary Language

EnglishSpanishOther
Other Languages Spoken:

SpanishGermanHaitian CreoleArabicChineseJapaneseOther
Number of Children:*
Ages of Children:
Children 18 and under?

YesNo
Which best decribes you:*

African AmericanAsianCaucasianHispanic/LatinoHawaiian / Pacific IslanderNative AmericanMulti-RacialOther
Marital Status:*

SingleMarriedDivorcedSeparatedWidowedDomestic PartnerCommon Law

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

Mentee Referral Form – Part B

Activities and Hobbies