WIPM Mentorship Survey
Mentees
Name
First Name
Last Name
Credentials
Email
example@example.com
Background & Goals
What is your current practice setting?
Medical Student
Resident
Fellow
Early Career attending (0-5 years)
Mid-career (5-10 years)
Career transition or re-entry
Other
Which of the following tracks are you most interested in exploring or receiving mentorship in? (Select up to 3)
Surgical & Interventional Procedures
Integrative, Functional & Medical Wellness
Practice Management & Business of Medicine
ASC & Investment Strategies
Research, Publishing & Innovation
Advocacy, Policy & Leadership
Education & Professional Development
Work-Life Integration & Career Longevity
DEI/Representation in Medicine
What are your top 1-2 growth or development goals for the next year?
Preferences & Learning Style
Are you open to mentoring:
A one-on-one mentor
A small mentorship group
Either is fine
Would having a mentor in your geographic region be helpful?
Yes
No
Prefer virtual regardless of location
How do you best learn and connect? (Select top 2)
Direct conversation and Q&A
Case reviews or clinical examples
Written guides or resources
Observational (watching procedures or listening to speakers)
Hands-on/live demonstrations
Group discussions
How often would you like to engage with your mentor?
Monthly
Every 6 weeks
Quarterly
Flexible/as needed
Do you prefer a mentor who is:
Highly structured with check-ins and action plans
More casual and conversational
A mix of both
What motivates you most in a mentorship experience?
Building a long-term connection
Learning specific skills or knowledge
Feeling supported during career transitions
Networking and career advacement
Other
Any additional comments that might aid in the pairing process?
Submit
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