Thank you for taking the time to complete this form.

The following questions are to be answered prior to your first mentoring session with Flint. They are designed to both check your eligibility for mentoring, and to help establish a good foundation and understanding of your needs, ready for our future work together.

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Name

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Age

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Phone

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Address (Optional)

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Ethnicity

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Occupation

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Faith or Religion

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Relational Status

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Number of Dependent Children

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Sexual Orientation

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Have you ever purchased sex?

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Please answer the following questions based on your recent experience.

  Yes No Unsure
1. Do you often find yourself pre-occupied with sexual thoughts?
2. Do you feel controlled by your sexual desire?
3. Do you hide some of your sexual behaviour from others?
4. Do you feel depressed or discouraged about some aspect of your sexual behaviour?
5. Has anyone else been hurt emotionally because of your sexual behaviour?
6. Have you sought counselling for an aspect of your sexual behaviour? (Outside of Flint)

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Do you have any drug or alcohol addictions? (If yes, please specify)

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Do you have any mental health issues? (If yes, please specify)

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How did you hear about the Flint programme?

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What days and times would be best for you to have mentoring sessions? (We will do our best to be as flexible as possible)

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What method of communication would you prefer for your mentoring sessions?

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We are a Christian charity, but welcome people of all faiths and none - knowing this, would you prefer your mentoring sessions to be faith based, focusing on scripture and prayer, or based on a secular counselling approach? (We offer both)

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What are your best hopes from attending Flint mentoring?

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Full Name

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Date

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