Course Intake Form – Mentorship Program Course Intake Form: Mentorship Program PERSONAL INFORMATION First Name Last Name Address City Postal Code Daytime Phone (and/or) Cell Phone Email address Profession OccupationEmployer City Country Referral How did you find out about these services? Professional Training List diplomas and pertinent certification or programs including dates of completion? Work Setting Describe the following: Who are your clientele? What are the types of issues you address in the therapy session? How many years’ experience do you have as a therapist? What are your strengths? What do you hope to gain by taking the Mentorship Program?