Thank you for taking the time to complete this form.

The following questions help us to check your eligibility for mentoring, and to establish a good foundation and understanding of your needs, ready for our future work together.

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Name (Required.)

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Age (Required.)

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Phone (Required.)

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Have you ever purchased sex? (Required.)

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Please answer the following questions based on your recent experience. (Required.)

  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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Below are some statements about feelings and thoughts.

Please tick the answer that best describes your experience of each over the last 2 weeks.

  None of the time (1) Rarely (2) Some of the time (3) Often (4) All of the time (5)
I've been feeling optimistic about the future
I've been feeling useful
I've been feeling relaxed
I've been feeling interested in other people
I've had energy to spare
I've been dealing with problems well
I've been thinking clearly
I've been feeling good about myself
I've been feeling close to other people
I've been feeling confident
I've been able to make up my own mind about things
I've been feeling loved
I've been interested in new things
I've been feeling cheerful

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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) (Required.)

Terms of Mentoring - Please read the following terms carefully.

The term "mentee" refers to those who come to us for help.
Where “we” is used, it refers to Flint.

These terms are intended to help ensure that mentoring is safe, helpful and effective, and to avoid misunderstandings.
  • Christian ethos: Flint's work is motivated by Christian values. A spiritual perspective can be included if you wish, but we are equally happy to work in a secular way.
  • Supervision: All Flint mentors receive regular supervision and may discuss their mentoring work with their supervisor.
  • Confidentiality: We respect your right to confidentiality. However, there may be circumstances in which we need to share information, particularly where there are serious safeguarding concerns, a significant risk of harm to you or someone else, or where disclosure is required by law. Wherever possible and appropriate, we will discuss this with you first.
  • Records and privacy: Brief summary notes may be kept securely, either in locked storage or on password-protected systems. You may ask to see the information we hold about you.
  • Cost: Mentoring is available regardless of ability to pay. Donations towards the work of Flint are welcome but are entirely voluntary.
Complaints
If you are unhappy with the mentoring you receive, we encourage you to speak to your mentor where possible. If the issue cannot be resolved, or you do not feel able to speak to them, you can contact the Flint Project Manager:

Ben Scott
PO Box 1290
Luton LU1 9HZ
ben@azalea.org.uk
By submitting this form, you agree to the terms set out on this mentoring agreement and will co-operate, to the best of your ability, with your Mentor.

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Date (Required.)

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