Mentoree Application
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Welcome Back Tarrant County Mentoree Application Cornerstone Network Assistance
Mentor Name: First
M.I
Last
Street
City
State
Address:
Phone: ( )
( Home
D.O.B.: __/__/____
)
(
)
Work Age:____
Zip Code
Cell
TDJC ID/REG.#:
Social Security Number:
Gender: Male/Female
State Issued:
Marital Status: Single Married Divorced Separated Widowed
Number of Children (circle): 1 2 3 4 5 6, ____ Name
Age
Do you have visiting rights with your children? Yes
Gender
No
Are you receiving any government assistance: (i.e., food stamps, social security, disability, etc) Yes No If yes, what type of assistance are you receiving?
Ethnicity:
What Language Do You Speak: Eng., Spanish. Other
Church/Organization Affiliation:
Weclome Back Tarrant County Mentoree application (cont.)
2009
Church/Organization Address: StreetCityStateZip Code Church/Organization Phone#:
(
)
Education Highest Level of School Attended: High School: Year
Where:
GED:
Year
Where:
College:
Year
Where:
Any courses or certificates earned while incarcerated:
Would you be interested in going to college or vocational training? If so, what courses or training are you interested in?
Do you currently have a valid driver’s license? Yes
No
What type of work skills do you possess?
What type of work did you do before your incarceration?
How long did you hold this position?
Briefly explain why are you interested in being mentored?
Welcome Back Tarrant County Mentoree Application | Confidential
2009
Weclome Back Tarrant County Mentoree application (cont.)
Do you attend services regularly? Yes
No Please share with us what church activities you are
actively involved in?
Does your church have a Prison Ministry? If not, how will your church support your mentoree efforts?
Medical History List any medical or mental problems:
Do you have any physical impairments? Yes
No If so, what kind?
Are you currently using any prescribed medication(s): Yes
No If so, list medications below:
Have you experienced depression, anxiety, or thoughts of suicide? Yes explain:
Have you ever been hospitalized for mental illness? Yes medical facility:
No If so, please
No If yes, how long, and which
Were you ever sexually abused as a child or while incarcerated? Yes you receiving counseling? Yes No
No If so, did you or are
Welcome Back Tarrant County Mentoree Application | Confidential
2009
Weclome Back Tarrant County Mentoree application (cont.)
In the past ten (10) years have you had a medical finding of or have you received medical treatment for acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC), HIV or any other disorder of the immune system? Yes No If so, please explain:
Substance Abuse Alcohol use? Yes Drug use? Yes
No Duration of time: No Duration of time:
Cigarette use? Yes
No Duration of time:
Have you or are you taking substance abuse treatment (i.e., AA, NA, Celebrate Recovery)? Yes
No If so, where and when:
Family History Are your parents still living? Yes Do you have any siblings? Yes
No No
Can you commit to at least one (1) year of being mentored? Yes
No
Does your family support your being mentored? Yes Are you continuing to grow in your Christian walk? Yes Are you currently on parole or probation? Yes
No No
No
If yes, please provide your Parole Officer’s name: When does your parole end?
I understand that the information given by me in this application will be verified and that any false or omission of facts associated with this application may result in either denial of mentoring or dismissal from the Welcome Back Tarrant County Mentor Program. I certify that the answers and statements given by me on this application are complete and true to the best of my knowledge and credence. Signature
Date:
Welcome Back Tarrant County Mentoree Application | Confidential
Mentor Name: First
M.I
Last
Street
City
State
Address:
Phone: ( )
( Home
D.O.B.: __/__/____
)
(
)
Work Age:____
Zip Code
Cell
TDJC ID/REG.#:
Social Security Number:
Gender: Male/Female
State Issued:
Marital Status: Single Married Divorced Separated Widowed
Number of Children (circle): 1 2 3 4 5 6, ____ Name
Age
Do you have visiting rights with your children? Yes
Gender
No
Are you receiving any government assistance: (i.e., food stamps, social security, disability, etc) Yes No If yes, what type of assistance are you receiving?
Ethnicity:
What Language Do You Speak: Eng., Spanish. Other
Church/Organization Affiliation:
Weclome Back Tarrant County Mentoree application (cont.)
2009
Church/Organization Address: StreetCityStateZip Code Church/Organization Phone#:
(
)
Education Highest Level of School Attended: High School: Year
Where:
GED:
Year
Where:
College:
Year
Where:
Any courses or certificates earned while incarcerated:
Would you be interested in going to college or vocational training? If so, what courses or training are you interested in?
Do you currently have a valid driver’s license? Yes
No
What type of work skills do you possess?
What type of work did you do before your incarceration?
How long did you hold this position?
Briefly explain why are you interested in being mentored?
Welcome Back Tarrant County Mentoree Application | Confidential
2009
Weclome Back Tarrant County Mentoree application (cont.)
Do you attend services regularly? Yes
No Please share with us what church activities you are
actively involved in?
Does your church have a Prison Ministry? If not, how will your church support your mentoree efforts?
Medical History List any medical or mental problems:
Do you have any physical impairments? Yes
No If so, what kind?
Are you currently using any prescribed medication(s): Yes
No If so, list medications below:
Have you experienced depression, anxiety, or thoughts of suicide? Yes explain:
Have you ever been hospitalized for mental illness? Yes medical facility:
No If so, please
No If yes, how long, and which
Were you ever sexually abused as a child or while incarcerated? Yes you receiving counseling? Yes No
No If so, did you or are
Welcome Back Tarrant County Mentoree Application | Confidential
2009
Weclome Back Tarrant County Mentoree application (cont.)
In the past ten (10) years have you had a medical finding of or have you received medical treatment for acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC), HIV or any other disorder of the immune system? Yes No If so, please explain:
Substance Abuse Alcohol use? Yes Drug use? Yes
No Duration of time: No Duration of time:
Cigarette use? Yes
No Duration of time:
Have you or are you taking substance abuse treatment (i.e., AA, NA, Celebrate Recovery)? Yes
No If so, where and when:
Family History Are your parents still living? Yes Do you have any siblings? Yes
No No
Can you commit to at least one (1) year of being mentored? Yes
No
Does your family support your being mentored? Yes Are you continuing to grow in your Christian walk? Yes Are you currently on parole or probation? Yes
No No
No
If yes, please provide your Parole Officer’s name: When does your parole end?
I understand that the information given by me in this application will be verified and that any false or omission of facts associated with this application may result in either denial of mentoring or dismissal from the Welcome Back Tarrant County Mentor Program. I certify that the answers and statements given by me on this application are complete and true to the best of my knowledge and credence. Signature
Date:
Welcome Back Tarrant County Mentoree Application | Confidential
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