Please complete all fields to the best of your ability.
Please note, parental/guardian consent is required for ALL mentor sessions for individuals under the age of 18.
MENTOREE GENERAL INFORMATION
MENTOREE MENTAL HEALTH INFORMATION
MENTOR SESSION INFORMATION
EMERGENCY CONTACT INFORMATION
In the event you feel the mentoree is a threat to their own well beingImmediately contact 911
STATEMENT OF TRANSPARENCY
*1-on-1 mentor sessions conducted by UMTR2ME are done in a manner to support and encourage mentorees to seek proper professional care by a licensed health care provider. *At no time will any mentor or representative of UMTR2ME give advice with regard to medical treatment and or make medication recommendations. *UMTR2ME will always recommend and make referrals to seek out properly trained and licensed medical professionals, and health care providers.
By entering the captcha below you are stating that you have read and fully understand the UMTR2ME-You Matter To Me Statement of Transparency (Part-5).
By clicking the submit button you are stating that you have read and fully understand the UMTR2ME-You Matter To Me Statement of Transparency