Mentoring Support Application
Those interested in receiving mentoring support with OCD Texas should submit the following information. Opportunities may be available at varying formats, frequencies, and inquiry types. Your responses will be used to support your interests, match your needs with the experience of mentors, and enhance the potential for a fulfilling experience for all.

By agreeing to complete this application, you are consenting to participate in the mentoring program. If you would like to participate, you can complete the survey below.

Email address *
Email address *
Your answer
First Name *
Your answer
Last Name *
Your answer
Primary phone (xxx-xxx-xxxx) *
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip *
Your answer
Emergency Contact Full Name *
Your answer
Emergency Contact Phone Number *
Your answer
Birth date *
MM
/
DD
/
YYYY
Are you over 18? *
Employment Information
If under 18, parent/guarding full name and phone number:
Your answer
How often are you interested in participating in mentorship activities?
What format of communication do you prefer for your experience and general information about OCD treatment?
What level of therapy experience do you have?
Please indicate any concerns with the following *
Required
Endorsing any of the above concerns does not disqualify an applicant from mentorship, but we would like to know more. Please describe:
Your answer
Primary diagnoses:
Your answer
Secondary diagnoses:
Your answer
Medical Conditions:
Your answer
What questions do you have for a peer mentor? *
Your answer
What do you hope to gain from hearing the personal experience of a peer mentor?
Your answer
Provider Name:
Your answer
Provider Contact Phone Number:
Your answer
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