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Modern Work Desk

Intake
Form
 

FACTS Outreach Mentorship Intake Form

Please complete the form below to begin your mentoring journey.

Basic Information

Are you completing this form for yourself or someone else?

Pick one
Myself
Parent/Guardian
Other

Current Status

Pick one
Student
Employed
Unemployed
Other

Mentorship needs

What are you currently seeking support with? (Select all that apply)

Goals

Commitment & Availability

Are you willing to commit to regular mentorship sessions?
Yes
No
Unsure
Preferred meeting type:
In person
Virtual
Either

Accountability & Mindset

Are you open to feedback and accountability?
Yes
No

Safety & Support

Do you currently have a support system?
Yes
No
Would you like someone from FACTS Outreach Services to follow up with you directly?
Yes
No

Consent

I understand that FACTS Outreach Services provides mentorship and guidance, not licensed counseling or therapy. If you are in immediate danger or experiencing a mental health emergency, please contact 911, local emergency or licensed crisis professional.
Yes/Agree
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Date
Month
Day
Year

Let’s Work Together

Get in touch so we can start working together.

  • Facebook
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  • LinkedIn
  • Instagram

Thanks for submitting!

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