ISSWSH Fellow Mentor Form

ISSWSH Fellow Mentor Form

Please fill out the below information
Name*

First NameLast NameCredentials
Which is your preferred contact method?*

PhoneEmailBoth
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Total number of years as an ISSWSH Fellow (If applicable):
Type of sexual health professional (check all that apply):

ResearcherClinicianPhysical TherapistSex TherapistSex CounselorPain SpecialistOther
Years in sexual health practice/research
AASECT Certified:

YesNo
Mentorship Type (check all that apply):*

Clinical Advice (virtual)Case Consultation (virtual)Research CollaborationShadowing (In person)Fellowship (In person)Other
Clinical Information (If applicaple)
Name
Location
Please explain your sexual health clinic/Type of practice setting (check all that apply)::

RuralAcademic hospitalUrbanPrivate practiceFee-for-ServiceConciergeSuburbanCatholic hospital
Do you have a dedicated sexual health practice?

YesNo
How many hours a week doing sexual health (provide details as needed)?
Do you treat ALL female sexual dysfunction conditions?

YesNo
If no, please briefly state the conditions or groups of conditions you treat.
Do you treat ALL male sexual dysfunction conditions?

YesNo
If no, please briefly state the conditions or groups of conditions you treat.
Do you treat trans/nonbinary conditions?

YesNo
If yes, briefly state the conditions or groups of conditions you treat.
Do you treat pediatric conditions?

YesNo
If yes, briefly state the conditions or groups of conditions you treat.
Describe the distribution of conditions seen in your practice.
Describe the patient demographic you serve (Eg. age/culture/ability/race/sexual orientation/education/income).
Researcher Information (If applicable)
Name of Institution
Location of Institution
Description of research (check all that apply):

ClinicalBasic scienceTranslationalFSDMale SDMale & female SDLGBTQIA+AdolescentPediatricMenopauseOrgasmHSDDArousalSexual painDermatopathologyNeuroscienceOther
Describe the demographic in your research.
Brief description of current research focus.
Mentor Availability

Please contact the mentee to discuss details of mentorship schedule.
Mentorship Fee?

YesNo
If Yes, Amount?
Statement of Mentorship Agreement
I, First Name Last Name , hereby declare that the information I have provided is true and correct. As an International Society for the Study of Women's Sexual Health (ISSWSH) Fellow Mentor I agree to provide mentorship in adherence to standard evidence-based medicine and all ISSWSH guidelines, position statements and publications, highlighting off-label treatment options. I further agree that the Mentor/Mentee agreement is and shall be governed by the bylaws of the society.
Clear
Should be Empty: