Mentoring Intake Form

NOTE: I Refrain from working with individuals experiencing substance addictions or psychiatric conditions. My expertise does not encompass these areas.

First Name

Last Name

Email

Phone / Mobile

Country of Residence

Date of Birth

Month

Day

Year

Sex

Female

Male

Have you ever taken antidepressants or been diagnosed with a mental illness? Explain briefly. NOTE: I Refrain from working with individuals experiencing substance addictions or psychiatric conditions. My expertise does not encompass these areas.

Are you currently taking any pharmaceutical medications? If so, please provide details. Sharing this information is entirely voluntary and at your discretion, with your consent.

Do you currently consume alcohol or use recreational substances? If so, please describe types and frequency of use.

How do you deal with stress?

Have you participated in mentoring or coaching before?

Yes

No

What are your personal mentoring goals and why do you want to achieve them?

Yes, subscribe me to your Newsletter

Iliana Rojero

mentoring & oracle

Mentoring Intake Form

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