Mentor/Mentee Interest Form
January 2025 Start
Name
*
First Name
Last Name
Degree
Email
*
RegID number
Location
*
Street Address
Street Address Line 2
City
State/Province/Territory
Zip Code
I'm interested in:
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Being a mentee
Being a mentor
Being both a mentee and a mentor
Would you be willing to be in a mentoring group, with multiple mentees to one mentor?
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Yes
No
In your ideal mentoring structure, how frequently are you connecting with your mentor/mentee?
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Daily
Once per week
2-3 times per month
Once per month
What best describes the stage of your career?
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Doctoral Student or Trainee
Early Career
Mid Career
Senior
Retired
How many years have you been licensed as a psychologist?
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What area are you most looking to focus on in this mentoring experience?
Clinical expertise in a certain practice area
Working with specific populations
Professional development within the existing work setting
Career trajectory and advancement
Something else
Briefly, please tell us what specific area, population, work setting, or trajectory you are referring to above.
Mentors: Please indicate which of the following are your clinical areas of expertise/interest. Select as many of the following that feel relevant, and leave those which don't blank.
Yes
Addiction Psychology
Assessment
Behavioral and Cognitive Psychology
Child and Adolescent Psychology
Counseling Psychology
Couple Psychotherapy
Family Psychotherapy
Forensic Evaluation
Gender-Affirming Care
Geropsychology
Group Psychology
Health Psychology
Individual Psychotherapy
LGBTQ+ Affirming Care
Neuropsychology
Organizational Psychology
Prescribing Psychology
Psychoanalytic/dynamic Psychotherapy
Racial and Ethnic Stress and Trauma
Rehabilitation Psychology
School Psychology
Serious Mental Illness
Substance Use Disorder/Addiction
Mentees: Please indicate which of the following are your clinical areas of expertise/interest OR which areas you'd like your mentor to be interested in. Select as many of the following that feel relevant, and leave those which don't blank.
Yes
Addiction Psychology
Assessment
Behavioral and Cognitive Psychology
Child and Adolescent Psychology
Counseling Psychology
Couple Psychotherapy
Family Psychotherapy
Forensic Evaluation
Gender-Affirming Care
Geropsychology
Group Psychology
Health Psychology
Individual Psychotherapy
LGBTQ+ Affirming Care
Neuropsychology
Organizational Psychology
Prescribing Psychology
Psychoanalytic/dynamic Psychotherapy
Racial and Ethnic Stress and Trauma
Rehabilitation Psychology
School Psychology
Serious Mental Illness
Substance Use Disorder/Addiction
Mentors: Please indicate which of the following achievements you would feel capable of helping a mentee with? Select as many of the following that feel relevant, and leave those which don't blank.
Yes
Balancing work and life responsibilities
Managing a staff
Navigating a career change
Negotiating a contract and/or salary
Organizational leadership
Overcoming burnout
Practicing self-care
Promotion and tenure
Public speaking and clinical training
Starting a practice
Supervising trainees
Transitioning to telepsychology
Writing and publishing
Mentees: Which of the following achievements would you like to focus on with your mentor? Select as many of the following that feels relevant, and leave those which don't blank.
Yes
Balancing work and life responsibilities
Managing a staff
Navigating a career change
Negotiating a contract and/or salary
Organizational leadership
Overcoming burnout
Practicing self-care
Promotion and tenure
Public speaking and clinical training
Starting a practice
Supervising trainees
Transitioning to telepsychology
Writing and publishing
Is it important to you that your mentor or mentee shares any of the following demographic qualities with you?
Yes
Male
Female
TGNC
LGBQ
Neurodivergent
Disability status
Religion
Race
Ethnicity
National origin
Let us know more about what you selected and we'll do our best to accomodate your preferences. Even if you don't have a preference when it comes to demographics, understanding how you identify will help us match you with a partner who is looking for a mentor/mentee like you.
Which selection criteria do you consider most important when finding you the best match?
Clinical areas of expertise
Personal and professional goals
Demographics
Are there any other details that we should take into account when matching you with a mentor or mentee?
Please review the
Terms & Conditions
*
I have read and agree to the Terms & Conditions of participating in this program.
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