ISSWSH Fellow Mentee Form
Requirements for Mentee:
ISSWSH membership dues must be current
Must be in good standing with your accreditation board (unless a trainee)
Must hold a valid, unrestricted license in your field (unless a trainee)
Must be in good standing with your training organization (no history of probationary action)
Name
*
First Name
Last Name
Credentials
Which is your preferred contact method?
*
Phone
Email
Both
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of sexual health professional you are seeking as a mentor (check all that apply):
*
Researcher
Clinician
Physical Therapist
Sex Therapist
Sex Counselor
Pain Specialist
Other
Mentorship Type (check all that apply):
*
Clinical Advice (virtual)
Case Consultation (virtual)
Research Collaboration
Shadowing (In person)
Fellowship (In person)
Other
Time Commitment: Please provide a description of the time anticipated or desired to spend on the mentorship.
Examples: XX hours/week for 1 week, 6 week immersion, 1-2 hours/year
Do you have a specific time frame for the mentorship?
Practice Information
Do you have a preference for sexual health practice type (check all that apply):
*
Rural
Academic hospital
Urban
Private practice
Fee-for-Service
Concierge
Suburban
Catholic hospital
Do you have a preference for patient type?
*
Female sexual dysfunction conditions
Male sexual dysfunction conditions
Trans/nonbinary conditions
Pediatric conditions
NO Preference
Researcher Information
Name of Institution
*
Location of Institution
*
Trainees: Anticipated year of graduation
*
Description of research interests (check all that apply):
*
Clinical
Basic science
Translational
FSD
Male SD
Male & female SD
LGBTQIA+
Adolescent
Pediatric
Menopause
Orgasm
HSDD
Arousal
Sexual pain
Dermatopathology
Neuroscience
Other
Brief description of current research interest(s)
*
Submit
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