Mentor Request: Online Form for an Impact Mentor

You will be contacted by the Impact City Mentorship Team to follow up within 48 hours

**Mentors are not licensed counselors. Mentors are trained to build relationships and stand in the gap as a friend offering wisdom, spiritual and practical guidance, perspective, accountability, a listening ear, and a specific next-steps to help an individual walk through a difficult season of their life.**

"Bear one another's burdens, and so fulfill the law of Christ"
-Galatians 6:2

Your name *

Last name

Email address *

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

Birthdate *

Gender *

Marital status *

Number of Children? *

Children's Ages?

Do you attend Impact City Church? *

If so, how long have you been attending?

Contact Preference? *

Phone Call

Text

Select the area that you would MOST like to meet with an Impact Mentor about. *

Abuse

Anger

Anxiety

Children/Parenting

Depression

Divorce

Finances

Grief

Health

Isolation

Marriage

Needing Forgiveness

New Christian and I have questions

Relationships with Others

Stress

Struggling with Faith

Substance Dependency

Unforgiveness Toward Others

Work/Life Balance

Spiritual Growth/Bible study

Other

I agree to meet with my mentor THREE times over the course of 6-8 weeks. *

I realize that I may be feeling better after one or two meetings, but the program is designed to support my next steps, which will require three meetings. My mentor is investing their personal time and energy into me and I agree to follow through.

I agree not to ignore my mentor when they communicate with me. *

Our mentors will hang with you in delays or life-circumstances! The program timeline is super flexible. But, please, honor their time and effort by communicating with them when they reach out to you.

Additional Information *

What would you like your mentor to know ahead of meeting you? Feel free to explain what is going on, specific areas you want to talk about, questions that you have, anything else that you would like share!

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Impact City Church
kelly@impactcity.church
7409638531

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