AADPRT Training Director Mentorship Program Interest Form

AADPRT Training Director Mentorship Program Interest Form

We're excited you're interested in connecting with other AADPRT members to develop a fruitful mentorship experience! Mentors and mentees can work together to discuss career development, troubleshoot workplace politics, brainstorm practical work/life strategies, or just about anything else. Please answer the questions below to help us match you with the right mentor or mentee.

Recommended Experience to be a Mentor: Asst/Assoc Training Director - at least 2-3 years; Training Director - at least 3 years

Isheeta Zalpuri, MD
Chair, Mentorship Committee
Name*

First NameLast Name
Program name*
Program size (# of residents/fellows)*
Program type*

Community-basedUniversity-basedVAOther
Program setting*

RuralSuburbanUrban
City/State*

Street Address

Street Address Line 2

CityState

Zip Code
Phone (must include valid area code)*
Please enter a valid phone number.
Email*

Confirmation EmailConfirm Email
Program category*

AddictionChild and AdolescentConsultation-LiaisonForensicGeneralGeriatricTriple BoardOther
Current position*

Training DirectorAssistant/Associate Training DirectorDirector of Psychotherapy TrainingDivision ChiefChairVice Chair/Director of Education/Academic ChairDean or Assistant/Associate DeanOther
Number of years in current position*
Number of years in education leadership (i.e. any of above roles)*
I'm interested in being a*

MentorMenteeBoth
Mentor Information

To best help us identify an appropriate mentee for you, please fill out the below information. If you are an Assistant or Associate Training Director, we recommend that you have had at least 2-3 years in the position before becoming a mentor. If you are a Training Director, we recommend that you have had at least 3 years in the position before signing up to be a mentor.
Please indicate the maximum number of mentees you would be willing, able, and interested in working with in a 1:1 mentorship relationship.*
As a Mentor, please check area(s) in which you feel you could be helpful.*

Career Development/NetworkingDeveloping Scholarly Project/Research; Grant WritingTeaching Issues/Curriculum Development; How to MentorAdministrative Issues/Time ManagementWork/life Balance; Burnout; SupportNew Program DevelopmentLeadership Development; Politics; NegotiationsRecruitment Regulatory Issues (NAS/Certification)Developing Workshops/Presentations/PostersPublications/WritingMedical/Legal IssuesRetirement Support for Minority FacultySmall or Community Program ConcernsOther
Would you be interested in mentoring a group of mentees interested in exploring a specific topic from the list below? (if interested in a particular topic, please list in other)

YesNo
As a Group Mentor, please check area(s) in which you feel you could be helpful.*

Career Development/NetworkingDeveloping Scholarly Project/Research; Grant WritingTeaching Issues/Curriculum Development; How to MentorAdministrative Issues/Time ManagementWork/life Balance; Burnout; SupportNew Program DevelopmentLeadership Development; Politics; NegotiationsRecruitment Regulatory Issues (NAS/Certification)Developing Workshops/Presentations/PostersPublications/WritingMedical/Legal IssuesRetirement Support for Minority FacultySmall or Community Program ConcernsOther
Is there anything else you could tell us about you that may help us pair you with the right mentee (e.g. particular interest, background, life experience)?
Mentee Information

To best help us identify an appropriate mentor for you, please fill out the below information.
As a Mentee, please check the area(s) you are looking to be mentored in*

Career Development/NetworkingDeveloping Scholarly Project/Research; Grant WritingTeaching Issues/Curriculum Development; How to MentorAdministrative Issues/Time ManagementWork/life Balance; Burnout; SupportNew Program DevelopmentLeadership Development; Politics; NegotiationsRecruitment Regulatory Issues (NAS/Certification)Developing Workshops/Presentations/PostersPublications/WritingMedical/Legal IssuesRetirement Support for Minority FacultySmall or Community Program ConcernsOther
Gender preference*

FemaleMaleNon-binary/Non-conformingNo preference
Preference for your mentor's career stage (check all that apply)*

Early (2-5 years)Mid (6-10 years)Lifer (11+ years)
Time zone preference*

EasternCentralMountainPacificAlaskaHawaiiNo preference
Diversity/Inclusion preference (check all that apply)

Underrepresented Minority (please specify below)LGBTQIIMG
Underrepresented minority description*
I prefer my mentor to be a:*

Training DirectorAssistant/Associate Training DirectorChairVice Chair/Director of Education
Preferred contact frequency*

MonthlyAt AADPRT and/or other meetingsNo preference - whatever happens is fineOther
Are you also interested in group (like-minded mentees paired with a mentor based on particular theme/task) or peer (like-minded mentees working with and mentoring each other on particular theme/task) mentoring?*

GroupPeerBothNone
As a Group or Peer Mentee, please check the area(s) you are looking to be mentored in*

Career Development/NetworkingDeveloping Scholarly Project/Research; Grant WritingTeaching Issues/Curriculum Development; How to MentorAdministrative Issues/Time ManagementWork/life Balance; Burnout; SupportNew Program DevelopmentLeadership Development; Politics; NegotiationsRecruitment Regulatory Issues (NAS/Certification)Developing Workshops/Presentations/PostersPublications/WritingMedical/Legal IssuesRetirement Support for Minority FacultySmall or Community Program ConcernsNothing specificOther
Is there anything else you would like to tell us about yourself that may help us pair you with the right mentor (e.g. particular interest, background, life experience)?
Is there anything else you would like to tell us about yourself that may help us pair you with the right mentee (e.g. particular interest, background, life experience)?
Thank you!
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