Xavier Mission's Life Skills Empowerment Programs (LSEP) 
Mentor Intake Form
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First and Last Name *
Home Address *
Cell Phone Number *
Email Address *
Age *
Race/Ethnicity *
Gender *
Education Level *
What is your occupation? *
How did you hear about LSEP? *
Have you ever been an LSEP mentor before?
 *
Who has been one of the most inspirational people in your life and in what way(s) have they positively impacted your life? *
Please give a brief description of any past experiences you have had serving as a mentor. What was most impactful about those experiences?
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Why did you decide to become an LSEP Mentor?
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What skills and gifts do you bring to LSEP?
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What are your hobbies and interests?
 *
Is there any relevant personal or professional experience that you think we should know about in matching you with a participant?
 *
Are there any concerns or questions you have about serving as a mentor? If so, please elaborate. 
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Do you have a gender preference for your mentee?
 *
Do you have an age preference for your mentee?
 *
Are there any other preferences you have for your participant?
 *
How do you hope to feel at the conclusion of your mentoring experience? *
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