Welcome Back Tarrant County

Mentoree Application
Cornerstone Network Assistance

Mentor Name:
First M.I Last

Address:
Street City State Zip Code

Phone: ( ) ( ) ( )
Home Work Cell

D.O.B.: __/__/____ Age:____ TDJC ID/REG.#:

Social Security Number: State Issued:

Gender: Male/Female Marital Status: Single Married Divorced Separated Widowed

Number of Children (circle): 1 2 3 4 5 6, ____

Name Age Gender

Do you have visiting rights with your children? Yes 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

Weclome Back Tarrant County Mentoree application (cont.) 2009

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 No If so, please
explain:

Have you ever been hospitalized for mental illness? Yes No If yes, how long, and which
medical facility:

Were you ever sexually abused as a child or while incarcerated? Yes No If so, did you or are
you receiving counseling? Yes No

Welcome Back Tarrant County Mentoree Application | Confidential

Weclome Back Tarrant County Mentoree application (cont.) 2009

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 No Duration of time:

Drug use? Yes 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 No

Do you have any siblings? Yes No

Can you commit to at least one (1) year of being mentored?

Yes No

Does your family support your being mentored? Yes No

Are you continuing to grow in your Christian walk? Yes No

Are you currently on parole or probation? Yes 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