Mentee Intake Form
Welcome to IMMIMEDI. We a non-profit organization founded with one purpose: To provide free guidance, support, and a safe space for students and families from different cultural and language backgrounds to discuss what the path to becoming a practicing provider in the USA entails. 

We welcome mentees and families of potential mentees who are immigrants and encountering difficulties navigating through the complicated medical education system. 

We are actively working to translate the form in different languages.


We are founded by immigrants and are here for our immigrant communities. 
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Are you the mentee or a parent/family member filling out for their child? *
Full Name *
Preferred method of contact? *
Preferred Email *
Phone Number
What is your ethnicity? *
What is your preferred language? *
Current Stage in Education *
What University/College is the mentee currently enrolled? 
Please write N/A if you are a parent(s) or if the mentee is currently in high school. 
Major(s) & Minor(s)
Graduation or Expected Graduation Date *
In what profession are you seeking mentorship and/or advisory sessions?  *
Please note at this time we have limited mentors for non-medical professional healthcare students and provider mentors. 
If you are seeking a (non-MD/DO) healthcare professional mentorship, please specify below 
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What are you looking to achieve from this program? *
Are you looking for advising session(s) or longitudinal mentorship? *
How did you hear about us? *
Please explain your background as it pertains to the immigrant focused approach of IMMIMEDI. *
Are there any concerns that have not been addressed in this form? Feel free to include any information that will help us better pair you with the right mentor.
Disclaimer Statement Please Read

IMMIMEDI is currently in its PRE-LAUNCH phase of our operation.


At this time, we are accepting a small group of mentees who will be paired with mentors in their preferred cultural and language backgrounds in a one-on-one setting until all mentors are paired. We would like to utilize this opportunity to optimize our mentor-mentee pairing process and relationship. We will be closely monitoring the communications at this time. Please forgive us as we send out continuous feedback forms to better our process. 


At IMMIMEDI, we believe in organic and spontaneous communication between mentors and mentees. Therefore, we do not set any requirements and restrictions on the number, type, and communication forms of mentorship sessions. If you feel uncomfortable with your mentor/mentee or have any concerns over your relationship, please do not hesitate to contact us at contact@immimedi.com and/or help us mediate your mentor/mentee relationship via the Feedback Forms.  


Please note that IMMIMEDI is a platform designated to provide mentorship in healthcare professional education within the USA and is not a platform for potential patients to seek medical advice. Therefore, we ask our mentees NOT to seek professional medical advice from IMMIMEDI-connected mentors. Furthermore, IMMIMEDI does not guarantee or generate any admission influences in any medical or healthcare professional programs. 


Last but most importantly, IMMIMEDI is a non-profit organization dedicated to providing free mentorships to interested students and families. We will never ask students and families for advanced payment or financial comprehension for our service. Eventually, as we formally launch our program, we hope to seek donations from mentees and families who wish to support our causes but not at this time. Our mentors are here to help and contribute voluntarily at this time, and they do not receive any form of financial comprehension from us. Please get in touch with us immediately ifs your mentor asks you for any form of monetary gain! 


Mentor Liability Disclaimer: https://www.immimedi.com/liability.html

Mentee Terms & Conditionshttps://www.immimedi.com/terms--conditions.html

Privacy Policy: https://www.immimedi.com/privacy-policy.html



By writing your name below, you read, understood, and agreed to our disclaimer Statements in its entity including Mentor Liability Disclaimer, Mentee Terms & Conditions, and Privacy Policy per above. You also agreed to be participating in our feedback communication to better IMMIMEDI's future pairing process and mentor-mentee relations.  *
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