MECR Career Mapping Intake Form

This form is designed to help Coach Q and the MECR Program build a personalized career pathway plan for youth in high school, college, postgraduate, or reentry phases.

Personal & Contact Details

Full Name

Preferred Name/Nickname

Email

Phone

Birthday

Day

Month

Year

Current location (City, State)

Current employment status

Employed

Unemployed

Student

Other

If employed/previously employed:

Current or most recent job title, employer, dates of

employment

Background & Experience

What’s your highest level of education completed (or in process) and major/field (if applicable)?

List any certifications, licenses, training, or programs you have completed.

Describe any previous work, volunteer, internship, or leadership experiences that helped you grow.

What is one achievement (academic, work‑related, or personal) you are proud of?

What challenges or barriers have you faced so far in education, employment, or re‑entry (if applicable)?

Self‑Knowledge: Interests, Skills & Values

What subjects, classes, or activities have you enjoyed the most (and why)?

What tasks or roles energize you (you feel “in the zone” doing them)?

What do you consider your top 3 strengths (skills/qualities), and why?

What are 1‑2 weaknesses, skill gaps, or areas you’d like to develop?

What values are most important to you in work/career? (Examples: helping others, creativity, stability, leadership, financial security)

How do you define success for yourself (in your career/life)?

Career Vision & Goals

If nothing held you back, what would your ideal job/career be in one sentence?

What are 2‑3 realistic career roles or fields you’re interested in exploring?

What is your short‑term goal (within the next 12 months)?

What is your mid‑term goal (1‑3 years)?

What is your long‑term goal (5 years or more)?

How much time, energy, or resources are you willing to commit (weekly/monthly) to achieve your short‑term goal?

Logistics & Readiness

What is your current availability (days/times) for mentoring/career‑mapping sessions?

Do you have reliable access to a computer/internet (for virtual sessions)?

Do you prefer virtual, in‑person, or hybrid mentoring?

Virtual

In‑Person

Hybrid

Are you willing/able to travel if needed for job‑shadowing, internships, or site visits?

Yes

No

Other

Are you open to relocating for work/training?

Yes

No

Maybe

Do you have transportation access (if required) or potential obstacles?

Barriers & Support Needs

What are the biggest barriers / concerns that might hold you back from your career goals?

What support do you currently have (mentors, family, programs, school, agency)?

In what areas would you like support or mentoring? (Check all that apply)

Career exploration / clarifying interests

Skill development (technical/hard skills)

Soft skills (communication, teamwork, leadership)

Resume/interview/portfolio prep

Networking/finding opportunities

Transition support (re‑entry, return to school)

Other

Is there anything in your history (criminal record, gap in employment/education, major life change) you’d like Coach Q to know about so we can plan accordingly? (optional)

Data & Outcome Tracking Consent

Are you willing to participate in follow‑up surveys/check‑ins at 3‑ and 6‑month intervals so we can measure impact?

Yes

No

Do you consent to share anonymized aggregate data (not individual names/details) for program reporting and success stories?

Yes

No

Photo/video consent: Do you consent to group photos/videos for marketing & program‑reporting purposes?

Yes

No

CAREER MAPPING FORM

MECR Career Mapping Intake Form

Personal & Contact Details

Background & Experience

Self‑Knowledge: Interests, Skills & Values

Career Vision & Goals

Logistics & Readiness

Barriers & Support Needs

Data & Outcome Tracking Consent