Graduate 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

Facebook Profile Name or URL

Emergency Contact (Optional)

Recommended for emergency purposes or program updates.

Name

First Name

Last Name

Phone Number

Email Address

Educational Background

What was your undergraduate major?

What is the highest level of college degree you have completed?

Bachelor’s degree

Master’s degree

Doctoral degree (PhD, EdD, etc.)

Professional degree (MD, JD, etc.)

Employment Information

Are you currently employed?

Yes

If yes, what is the name of your employer?

What is your current job title?

Community Engagement

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 ideal medical or healthcare career? What inspires you to pursue this path?

List the top 3 medical schools or healthcare programs you hope to attend.

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?

Graduate Mentee Intake Form

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