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* 1. Please enter the following:
Name
Age
Sexual Orientation (or "prefer not to answer")
Gender Identity (or "prefer not to answer")
Email
Phone number

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* 2. Are you apart of the LGBTQIA+ community?

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* 3. Why do you want to become a mentor?

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* 4. Do you understand that you will need to pay for a background check in order to participate as mentor in this program? Rainbow Embrace Physical Therapy (REPT) LLC is unable to cover background check costs at this time. Please wait until you have passed this initial screening and then I will let you know that you can proceed with a background check. REPT does not benefit from background checks, this is a free service, but REPT cannot pay for background checks at this time. Completing a background check WILL NOT automatically qualify you to be a mentor in this program.

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* 5. Are trans women women? 

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* 6. Are trans men men

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* 7. Do you have to experience gender dysphoria to be valid in the transgender community?

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* 8. Please list your social media account links below (these will never be shared, but I will use these to look into who you are):

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* 9. Do you understand that Rainbow Embrace Physical Therapy LLC and Dr. Samantha Hoover, DPT are not responsible for you or your mentees actions or words. This service is meant to connect mentors with mentees within the LGBTQIA+ community directly with each other, but you are responsible for your own actions. It is advised that you do not give medical advise and that you keep things PG between you and your mentee. You can always contact me if you have an issue with a mentee, but I am again not responsible for their actions. Do you understand the above statement?

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* 10. What similarities would you prefer between you and your mentee? Check all that apply.

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