{"id":1515,"date":"2026-09-19T20:47:52","date_gmt":"2026-09-19T20:47:52","guid":{"rendered":"https:\/\/mentoringmeinc.org\/?page_id=1515"},"modified":"2026-09-19T20:47:52","modified_gmt":"2026-09-19T20:47:52","slug":"request-services","status":"publish","type":"page","link":"https:\/\/mentoringmeinc.org\/?page_id=1515","title":{"rendered":"Request Services"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Interested in employment, transition, or career-readiness services? Complete the form below, and Mentoring Me Inc. will contact you about possible next steps.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Who this form is for<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Students with disabilities ages 14\u201321 who are enrolled in school<\/li>\n<li>Families seeking career exploration, work readiness, self-advocacy, postsecondary counseling, or work-based learning information<\/li>\n<li>Adults ages 16 and older who are interested in employment services<\/li>\n<li>Students, families, educators, and referral partners who are unsure which service is the right fit<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Submitting this form is a request for information. It does not guarantee eligibility, enrollment, services, or authorization from Florida Vocational Rehabilitation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Student Service Interest Form<\/h2>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1514-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1514\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1515#wpcf7-f1514-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1514\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1514-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p>Please complete this short form if you are interested in Mentoring Me Inc. services. We will review your information and contact you about possible next steps.\n<\/p>\n<p><strong>Please do not enter a diagnosis, Social Security number, medical information, VR case number, or upload confidential documents here.<\/strong>\n<\/p>\n<p><label> Student first and last name *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"student-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"student-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Parent, guardian, or primary contact name (if applicable)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"parent-guardian-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" autocomplete=\"name\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parent-guardian-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email address *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"contact-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone number *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" autocomplete=\"tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"contact-phone\" \/><\/span> <\/label>\n<\/p>\n<p><strong>Student age range *<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"student-age\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"student-age\" value=\"14\u201315\" \/><span class=\"wpcf7-list-item-label\">14\u201315<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"student-age\" value=\"16\u201317\" \/><span class=\"wpcf7-list-item-label\">16\u201317<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"student-age\" value=\"18\u201321\" \/><span class=\"wpcf7-list-item-label\">18\u201321<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"student-age\" value=\"22 or older\" \/><span class=\"wpcf7-list-item-label\">22 or older<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><strong>Is the student currently enrolled in school? *<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"enrolled-school\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"enrolled-school\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"enrolled-school\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> County *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"county\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"county\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Hillsborough\">Hillsborough<\/option><option value=\"Polk\">Polk<\/option><option value=\"Pasco\">Pasco<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> School, homeschool program, or other education program (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"school-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school-name\" \/><\/span> <\/label>\n<\/p>\n<p><strong>Which services are you interested in? Select all that apply.<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Work-Based Learning Experience (WBLE)\" \/><span class=\"wpcf7-list-item-label\">Work-Based Learning Experience (WBLE)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Job Exploration Counseling\" \/><span class=\"wpcf7-list-item-label\">Job Exploration Counseling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Workplace Readiness Training\" \/><span class=\"wpcf7-list-item-label\">Workplace Readiness Training<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Self-Advocacy Instruction\" \/><span class=\"wpcf7-list-item-label\">Self-Advocacy Instruction<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Postsecondary Education Counseling\" \/><span class=\"wpcf7-list-item-label\">Postsecondary Education Counseling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Adult Employment Services (ages 16+)\" \/><span class=\"wpcf7-list-item-label\">Adult Employment Services (ages 16+)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"services[]\" value=\"Not sure yet\" \/><span class=\"wpcf7-list-item-label\">Not sure yet<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><strong>Vocational Rehabilitation status *<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"vr-status\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"vr-status\" value=\"Already working with VR\" \/><span class=\"wpcf7-list-item-label\">Already working with VR<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"vr-status\" value=\"Referred to VR\" \/><span class=\"wpcf7-list-item-label\">Referred to VR<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"vr-status\" value=\"Not connected to VR\" \/><span class=\"wpcf7-list-item-label\">Not connected to VR<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"vr-status\" value=\"Not sure\" \/><span class=\"wpcf7-list-item-label\">Not sure<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><strong>Preferred contact method *<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-contact\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"preferred-contact\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"preferred-contact\" value=\"Phone call\" \/><span class=\"wpcf7-list-item-label\">Phone call<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"preferred-contact\" value=\"Text message\" \/><span class=\"wpcf7-list-item-label\">Text message<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> How did you hear about Mentoring Me Inc.? (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referral-source\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"referral-source\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"School or educator\">School or educator<\/option><option value=\"VR counselor\">VR counselor<\/option><option value=\"Parent or family member\">Parent or family member<\/option><option value=\"Social media\">Social media<\/option><option value=\"Website search\">Website search<\/option><option value=\"Community organization\">Community organization<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> Questions or information you would like us to know (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-info\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"additional-info\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consent-contact\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consent-contact\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I understand that this is a request for information and does not guarantee enrollment, eligibility, services, or VR authorization. I give Mentoring Me Inc. permission to contact me about services.<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email-updates\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"email-updates[]\" value=\"Yes, I would also like to receive Mentoring Me Inc. resources, student opportunities, and program updates by email. I understand that I can unsubscribe at any time.\" \/><span class=\"wpcf7-list-item-label\">Yes, I would also like to receive Mentoring Me Inc. resources, student opportunities, and program updates by email. I understand that I can unsubscribe at any time.<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Request Information\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\n\n\n<p class=\"wp-block-paragraph\">If you need help completing the form, email <a href=\"mailto:contactus@mentoringmeinc.org\">contactus@mentoringmeinc.org<\/a> or call <a href=\"tel:+18133644664\">(813) 364-4664<\/a> for Hillsborough\/Pasco or <a href=\"tel:+18633307332\">(863) 330-7332<\/a> for Polk County.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Interested in employment, transition, or career-readiness services? Complete the form below, and Mentoring Me Inc. will contact you about possible next steps. Who this form is for Students with disabilities ages 14\u201321 who are enrolled in school Families seeking career exploration, work readiness, self-advocacy, postsecondary counseling, or work-based learning information Adults ages 16 and older [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1515","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=\/wp\/v2\/pages\/1515","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1515"}],"version-history":[{"count":1,"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=\/wp\/v2\/pages\/1515\/revisions"}],"predecessor-version":[{"id":1516,"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=\/wp\/v2\/pages\/1515\/revisions\/1516"}],"wp:attachment":[{"href":"https:\/\/mentoringmeinc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1515"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}