Mentee Program Application

Thank you for your interest in taking part in the Choose To Be Restored Mentee Program. Please complete the following form to help us understand your needs and how we can best support you. Transformation is not always easy; however, our program will provide you with tools to guide you on your journey to hope and healing. Please know that you will be with women who also share what you are going through. Most of all, you will be surrounded by hope, love, and support. The following questions are designed so we can get to know you. This is not a test, and there are no right or wrong answers. Our goal is to help you in the best possible way, so, we encourage you to take a few minutes for yourself, relax, and think about the questions as you respond. Your information will be kept confidential. Thank you for your trust in Choose to be Restored. We look forward to supporting you on your journey to healing and restoration.

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Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

What Are You Looking For?

Please select areas you are seeking assistance with (check all that apply)

If other, please explain

Challenges & Stressors

Please describe the things you would like to overcome:

What are some of the things you are currently stressed about?

Additional Information

Is there anything else you would like us to know?

Legal & Program Information

Have You Been Convicted of a Felony?

If yes, please specify

Privacy & Security Disclaimer

By submitting this form, you agree to allow "Choose to be Restored" to use the information provided to tailor our support services to your needs. We are committed to protecting your privacy and will not share your personal information with any third parties without your consent. Your data is stored securely and only accessible to authorized personnel within our organization. Please note: We are not licensed counselors or therapists in the state of CA. Choose To Be Restored provides mentorship services to support personal growth and development. Please note that these services are not a substitute for professional counseling or therapy and our mentors are not licensed counselors or therapists. For any mental health concerns, we recommend seeking advice from a licensed professional.

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