TransMentee Intake Form
Any transgender client wanting to enter into our TransMentor Program as a mentee is to fill out this intake form. ::DISCLAIMER:: **The volunteer mentors are peer mentors and are NOT licensed medical or mental health professionals. Their thoughts and opinions are their own and do not necessarily represent those of Trans Empowerment Project. Any opinions/advice/suggestions/thoughts/etc. of any Mentor do NOT have to be taken or followed at all. If you feel that your mentor is acting inappropriately or have any issues whatsoever, you are free to contact James.Blake@transempowermentproject.com for assistance.**
Name *
Your answer
Date of Birth *
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DD
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YYYY
Phone
Please include at least one contact method
Your answer
Email
Please include at least one contact method
Your answer
Preferred Contact Method *
Please provide two emergency contacts with contact info: *
Your answer
How did you hear about the TransMentor Program?
Your answer
Have you ever been in a mentor program before?
What do you hope to gain by joining this program?
Your answer
What does being a "safe person" mean to you?
Your answer
What is your definition of a "safe space"?
Your answer
What is your definition of intersectionality? *
Your answer
Please list one or more goals you would like to achieve related to transition: *
Your answer
Please list one or more goals you would like to achieve related to education or employment: *
Your answer
Please list one or more personal goals you would to achieve: *
Your answer
What is your idea of a positive mentorship? *
Your answer
Do you have any religious preferences you would like us to keep in mind when matching you to a TransMentor?
Your answer
Do you have any allergies, such as to animals we should know about when matching you to a TransMentor?
Your answer
Have you had any mental health concerns in the past 6 months? *
If yes, please explain:
Your answer
Do you have any supportive family members?
Your answer
Do you know any other transgender people?
Have you have any suicidal thoughts in the last 6 months? *
Are you currently feeling like ending your life? *
Have you ever been convicted of a crime? If yes, explain: *
Your answer
We have two types of mentors available as an option, one may be a cisgender ally (such as: the parent of a trans child). Are you comfortable also having an ally available to you as a mentorship option? Please explain: *
Your answer
Do you consent to a background check? *
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