Prospective Mentee Meeting Request

Gender *

Male
Female

Age *

Name *

First

Last

Email *

Email

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Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Best time to call (include timezone pls) *

What is your profession?

Marital Status

How long?

Do you have children? *

Yes
No

What led you to contacting me today? *

What changes would you like to see the most in your life? *

What do you see as the biggest barriers to these changes you desire? *

Do you struggle with any addictions? *

No
Yes

Please explain how you struggle with addictions *

Have you had any issues with Depression, Anxiety, or ADD/ADHD (Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder)?

No
Yes

Please explain what issues you have or have had with depression, anxiety, ADD/ADHD *

Are you currently seeing a therapist? *

No
Yes

Please explain why you are receiving therapy

How many books do you read in a year? *

Average Annual Income *

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

What do you believe must happen in your life before you'll be ready to make such an investment into yourself?

A bit more about how you engage life

Do you get your energy from interaction with the world and people around you, or more from yourself, with your own activities and thoughts? *

The world around me
My own activities and thoughts

Does your info preferably come from observing, measuring, experience or from explanation, reasoning, more abstract understanding? *

From observing, measuring, experience
From explanation, reasoning, more abstract understanding

How do you make most decisions: by way of rational, logic, given decision criteria, or by looking at context, interests, what feels right? *

By Rational, logic, given decision criteria
By looking at context, interests, what feels right

How do you approach situations: should things go as planned and wanted, or are you flexible, open to change, go with the flow? *

I want things to go as planned and prefer black and white, concrete steps
I am flexible, open to change, and go with the flow

Would you like to receive a very occasional email newsletter? *

New emails are only sent when new blog posts or articles are posted.

Prospective Mentee Application

A bit more about how you engage life

I’m Looking Forward to Speaking

With You!