Client Application for LifeWorks Mentoring
Fill this out to start the process of getting a Mentor.
Personal Information
Name:
(Last)
(First)
(MI)
Address:
(Address)
(City)
(State)
(Zip)
Home Phone:
Cell Phone:
E-Mail Address:
Date of Birth:
Gender:
Marital Status:
Languages Spoken:
Employment
Employer:
Occupation:
Business Phone:
May we contact you at work?
Yes
No
Matching Information
This information is optional but may help us to make the most appropriate match.
Race/Ethnicity:
Age:
Sexual Orientation:
Gender Identity:
Highest Education Level Completed:
Referred by:
Other interests that will be helpful for LifeWorks Staff to know about:
Mentoring Questions
The following information is required:
1. What is Mentoring to you?
2. What has been your experience with LGBT adults?
3. What do you expect from a Mentor?
4. Explain what “boundaries” mean to you?
5. Have you ever been in a mentoring relationship?
6. What do you think are three of the biggest issues facing you and other Lesbian, Gay, Bisexual and Transgender (LGBT) youth?
7. What are some of the most important attributes that a mentor should possess?
8. Do you have any medical or mental health requirements that would need to be accommodated?
9. Why do want a mentor and what do you hope to gain from the experience?
10. What are the best times for you to attend LifeWorks Mentoring Activities?
Click "Submit Information" below, and we will be in touch with you soon about setting up an interview.
If you have further questions about the Mentoring Program please contact Dinorah Garcia, Client Consultant at
dgarcia@lifeworksmentoring.org
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