Prospective Mentee Application

Gender Gender Male Female Other

Age

Name

Email Address

Phone

Where do you live? (city, state, country)

What is your profession?

Marital Status Marital Status Domestic Partner Married Divorced Widowed Never Married

What led you to contacting me today?

In the next 6 months, what changes do you MOST want to see in your life?

What do you see as your biggest barriers to getting what you want?

Are you dealing with any past or current addictions? Are you dealing with any past or current addictions? No Yes

If yes, please describe

Have you had any issues with Depression, Anxiety, or ADD/ADHD (Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder)? Have you had any issues with Depression, Anxiety, or ADD/ADHD (Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder)? No Yes

If yes, please describe

Are you currently seeing a therapist? Are you currently seeing a therapist? No Yes

If yes, please describe

Average Annual Income Average Annual Income No income Low income Medium/Average income High income Wealthy

Why do you have no income?

How serious are you about beginning a mentoring program? How serious are you about beginning a mentoring program? I’m just looking into it but not ready to make a time or money investment in myself I’m serious and want to invest in myself, but I don’t know how to get going I’m ready to get going and make the necessary investments to do it

Best Phone Number to Call

Best time to call?

Is it okay to leave messages at these numbers? Is it okay to leave messages at these numbers? No Yes