College Mentee Intake Form

Please complete all required fields. Once you're done, you'll be redirected to schedule your first session.

Note: You must complete and submit the questionnaire in one sitting. Partial responses cannot be saved or resumed later.

Student Information

Name

First Name

Last Name

Date of Birth

YYYY

Age

Phone Number

Social Media

Instagram Handle

TikTok Username

Threads Username

Snapchat Username

Parent / Guardian Contact Information (Optional)

Recommended for emergency purposes or program updates.

Parent / Guardian Name

First Name

Last Name

Parent / Guardian Phone Number

Parent / Guardian Email Address

Educational Background

What is the name of the high school you graduated from?

What year did you graduate from high school?

What college or university do you currently attend?

What is your current major or degree program?

Are you currently enrolled in classes?

Yes

How many credits are you taking this semester?

What is the total number of college credits you have completed so far?

What is your current cumulative GPA?

Employment Information

Are you currently employed?

Yes

If yes, what is the name of your employer?

What is your current job title?

Volunteer & Community Involvement

List any current or past charitable or volunteer work you’ve participated in.

Approximately how many total hours of volunteer work have you completed?

Career Aspirations

What is your dream medical or healthcare career? Why are you passionate about this path?

List the names of your top three medical schools or healthcare programs you would like to be accepted into.

What steps do you believe are necessary to gain admission into the programs listed above?

Goal Setting

What are your personal and professional goals for the next 1–3 years?

What are your personal and professional goals for the next 4–5 years?

Challenges & Concerns

What fears or concerns do you have about being accepted into a healthcare or medical program?

What are your three biggest obstacles right now in your journey toward a healthcare program?

Support & Expectations

Who do you consider part of your support system? How do they support you?

What are your expectations for your experience with Accepted into Medicine with Eboné LeGall?

Personal Reflection

What does being dedicated mean to you?

What does it mean to you to work hard?

How would you describe professionalism, especially in the medical field?

Describe a recent situation where you did not follow through on a commitment or decided to quit. What happened, and what did you learn?

College Mentee Intake Form

What percentage of applicants get accepted into healthcare programs in the United States?