Ellen Perlman Simon Mentorship Program Application

Program Description

The Ellen Perlman Simon Mentorship Program provides SSWLHC members the opportunity to learn from other social work leaders and clinicians in health care and/or to serve as a mentor to colleagues developing key leadership skills. The Program creates the foundation for a meaningful mentoring experience by fostering an intentional and purposeful relationship guided by clearly defined goals.

Unlike clinical supervision, the mentor/mentee relationship focuses on and is guided by specific deliverables and goals. Mentees may choose to utilize their mentors for guidance and consultation toward the completion of a project (deliverable), or may identify goals related to more global skill development. Deliverables are intended to encompass and develop core leadership skills such as navigating professional dilemmas, strategic planning, or staff development, to name just a few. The Mentor/Mentee relationship is non-evaluative and is not meant to serve as clinical supervision.

Shorter-term consultation is also available to SSWLHC members through the Mentorship Program. Consultation is intended to assist members in navigating one-time or episodic projects or leadership challenges. Participants are encouraged to identify a goal to direct this work and to plan for a maximum of three consultation sessions.

Name

First NameLast Name

City and State

Time Zone:

Phone Number:

Email Address:

Years Within Position

Years in Profession

I am applying to become a:

MenteeMentor

Please briefly describe why you want to become a Mentor/Mentee:

Please briefly describe what types of skills you would like to develop or guide others to develop as part of the Mentorship Program and what you hope to gain from this experience?

Please upload your current CV/Resume:

Browse Files

Please indicate which of the core program areas you wish to explore as the basis for a mentoring relationship:

Have you had mentoring before?

YesNo

Your Preference of Communication with your Mentor

By signing below, I confirm that the information provided in this application is true to the best of my knowledge and that I have read and understand the program description and its requirements. I understand that the submission of this application does not guarantee my participation in the SSWLHC Mentorship Program and, if accepted, I may be placed on a wait list based upon availability of resources at the time of application. I understand that this information will be shared with mentor application committee and my chosen mentor.I also hereby agree to hold harmless and indemnify the Society for Social Work Leadership in Health Care, its officers, agents and employees from any and all liability, loss, damages, costs or expenses which are sustained or incurred in connection with or in the course of the Mentorship Program.