AADPRT PA Mentor Form

AADPRT Program Administrator Mentorship Interest Form

If you are a program administrator (coordinator) with interest in being a mentor or mentee, please complete this form and we'll be in touch soon.
Name*

First NameLast Name
Email*
example@example.com
Work phone (must include valid area code)*
Please enter a valid phone number.
Program Name:*
Region (click link below to view states by region):*

I - New EnglandII - New YorkIII - Mid-AtlanticIV - MidwestV - SoutheastVI - CaliforniaVII - Far West
View states by region
Program type:*

Community-basedUniversity-basedVAOther
Program setting:*

RuralSuburbanUrban
Number of trainees:*

1-1213-2425-4950+
Program(s) responsible for (select all that apply):*

Addiction PsychiatryBrain Injury MedicineChild and Adolescent PsychiatryCombined Psychiatry/Family PracticeCombined Psychiatry/MedicineCombined Psychiatry/NeurologyConsultation-liaison PsychiatryForensic PsychiatryGeneral PsychiatryGeriatric PsychiatryTriple Board ProgramOther
I'm interested in being a:*

MentorMenteeBoth
Program Administrator experience:*

Less than 1 year1-3 years4-5 years6-10 years11+ years
Gender preference*

FemaleMaleNon-binary/Non-conformingNo preference
Diversity/Inclusion preference (check all that apply)

Underrepresented Minority (please specify below)LGBTQI
Underrepresented minority description*
Preferred contact frequency*

MonthlyAt AADPRT Annual MeetingNo preferenceOther
Topics you'd like help with (mentees) or can help with (mentors):*

AI tools/utilizationAccreditation (milestones, ADS, APE, PEC, CCC)Advocating for yourself (pay raise, added job responsibilities)Anti-racism, justice, equity, diversity, inclusionBurnout/WellbeingCrisis/disaster managementC-TAGME certificationEvaluationsEvent planning (recruitment, orientation, graduation)IMGsInnovative practices and organizational strategiesInteracting with trainees/facultyLeadership skillsMedHub and new innovationsOnboardingProfessional developmentRecruitment (ERAS, NRMP, SOAP, the Match)Resident problems (documentation, probation, dismissal, etc.)Other
What are you hoping to gain from this experience?*
Anything else you'd like to tell us about yourself that may help us best match you (e.g. interests, background, life experience)?
Thank You!
Should be Empty:

AADPRT Program Administrator Mentorship Interest Form