Request for Mentor (Combined).doc

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REQUEST FOR MENTOR Mentors may come from community and faith-based organizations or individuals and IDOC does not guarantee that a mentor will be assigned. Participation is completely voluntary for both parties and can be terminated by either party of IDOC staff at any time without affecting release eligibility or violation determination. Nothing replaces the work of your counselors, case managers, or probation and parole officers for housing, employment, and conditions of supervision. It is your responsibility (not the mentor’s) to keep them informed of your needs, plans, and any changes. A mentor can help you transition back into the community and become a positive and productive member of society, but success is ultimately up to you because you are Free2Succeed. Typically, consideration for a mentor will be within 90 days of a release date. The request will be returned if outside that timeframe. Last name: _________ __ First: __________________________ IDOC #: _____ Age: ________ Male Female Are you a veteran? Yes No Are you currently: (Please choose a status and answer all questions as accurately as possible) INCARCERATED: Termer Rider Parole Violator Probation Current institution: _________________ Name of case manager: ___________________________________ Anticipated release to: City: __________________ County: _______________ Month: _______ Year: ______ COMMUNITY SUPERVISION: Probation Parole D1 D2 D3 D4 D5 D6 D7 Current city: ___________________________________ P&P officer: ________________________________ Level of Supervision (if known): LSU (WBOR) Limited 2 3 4 Court supervision: Mental Health Veterans Drug Family Other _____________________ Faith-based (religious) affiliation: Yes No What church or religion: Do you have an individual in mind for a mentor? Yes No Current IDOC Volunteer: Yes No Last Name: ____________________________________ First Name: _________________________ Is this person aware you are interested in them as a mentor to you? Yes No If known, contact information: __________________________________________________________ The language I speak is: English Spanish Other: _________________________________ Do you have a residence upon release? Yes No Address of residence upon release (if known): ________________________________________________________________________________________ Street ________________________________________________________________________________________ City State Zip Do you have a spouse or significant other that you would like your mentor to contact? Yes No If yes, how do you want the contact made (phone, visit, etc.)? ______________________________________ Do you have any immediate needs that will need to be addressed after your release? _______ ____________ Are there any specific issues you would like your mentor to be aware of? _________________ ___________ Do you have a job waiting for you upon release? Yes No Maybe If yes, what is the name of the employer: _______________________________________________________ What job skills do you have? ____________ ___________ What is the highest level of education that you have completed? High school diploma GED Technical school (field of study) __________________ Some college (field of study) ________________________________________________________ College degree (type of degree and field) ______________________________________________ What results do you expect from having a mentor? _______________________ ___________ ___________ What age group do you want you mentor to be: 25-35 36-45 46-55 56+ Any Please list a few hobbies or interests. _______ _______________________ ___________ (OPTIONAL) Do you have health issues you would like to discuss with your mentor? Yes No Information shared between the offender and the mentor is not strictly confidential. Mentors must report the following information to IDOC staff involving one or more of the following: a threat to facility security harm to self or others criminal activity violation of and condition of probation or parole violation of any rule violation of a no-contact order