WIH Texas Mentorship Survey

Texas Chapter Women in Healthcare Mentorship Program Questionnaire

Thank you for your interest in the Women In Healthcare Texas Mentorship Program. The Program is a six month engagement where mentors and mentees are encouraged to connect regularly to discuss mentees' goals. The WIH Texas Chapter leadership team supports each mentorship pair with resources and advice to help you develop your engagement.
Please complete the survey below to be paired with a mentor/mentee. We ask that you answer honestly and accurately, as your responses will help in creating a successful pairing. This survey should take you 5-10 mintues to complete.
Full Name*

First NameLast Name
E-mail
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title:*
If student, please mention your degree
How did you hear about WIH Mentorship Program?

WIH LinkedIn PageWIH EmailWIH InstagramWIH WebsiteReferral from a friend/coworkerEmploymentOther
Are you working from home or office?

HomeOfficeBoth
Are you intending to be a mentor or mentee?

MentorMentee
How often do you want to be in contact with your mentor/mentee?*

Bi-weeklyMonthly
Time preference for events (check all that apply)

MorningMid-DayEvening
Please choose your referred communication method

In-personVideo conferencePhoneEmail
When you think about communicating with your mentor/mentee, how do you envision the relationship?

More casual – we will contact each other when we want to talk, knowing that the other person will be available for me when needed.More structured – we will schedule phone calls, e-mails, or personal meetings to ensure we keep up with one another.
Of the list below, please pick the top two that would best apply to what you want out of the mentorship program

Career DevelopmentCommunication skills and styleProfessionalismKnowledge and exposure
Do you want to be paired within your current field/concentration?

YesNoNo preferenceUnsure
Have you ever been a mentee before? If "Yes," please describe your experience (e.g., what worked well; didn't work)Type a question
Have you ever been a mentor before? If "Yes," please describe your experience (e.g., what worked well; didn't work)
What are your professional goals in the next 12-24 months?
A few words
Do you know what field of Healthcare you want to work? If unsure, please provide your interest(s).
For mentee: What are a couple of the major challenges you are experiencing and trying to overcome in your role at the moment?
For mentor: Please briefly descride how you would help your mentee overcome a professional challenge or road block.
When you think about the success of the mentor/mentee relationship, how do you envision the relationship and what are your measures for success?
What are your hobbies outside of work?
**We ask if you commit to being a mentor/mentee, you take the commitment seriously. The Mentorship Chairs are available with any questions or concerns during the process, and to make any necessary changes if someone is not getting what they need out of the program.**
Should be Empty:

Texas Chapter Women in Healthcare Mentorship Program Questionnaire