Austin Psychoanalytic Mentoring Application
Note: Participation in the Mentoring program requires membership in Austin Psychoanalytic.
Name
*
First Name
Last Name
Preferred Pronoun(s)
Optional
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Granting Institution (Or current institution)
Year graduated
Type of Degree
Licensure / Credential
Agency / Type of practice (Please describe work that you do.)
Do you have a specialization or particular area of interest? If so, please describe.
What piqued your interest in having a mentor?
What might you want to focus on with your mentor?
What led you to your interest in psychoanalytic / psychodynamic thinking and/or it's application to your clinical work?
Preferences for location (check ALL that apply)
North Austin
East Austin
Central Austin
South Austin
Other
Preference for meeting times (Please include any specific day/time preferences under "other"
Week days
Week nights
Weekends
Other
Are you able to attend at least one Austin Psychoanalytic monthly meeting in the fall and spring?
Yes
No
Are you a member of Austin Psychoanalytic
Yes
No
Please share with us any other factors you would like us to consider when matching you with a mentor. (Such as age, culture / ethnicity, mobility restrictions, etc.)
How did you hear about mentoring program?
Submit
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