WIPM Mentorship Survey
Mentors
Name
First Name
Last Name
Credentials
Email
example@example.com
Background & Experience
What is your current practice setting?
Academic Faculty
Private Practice - Solo
Private Practice - Group
Hospital Employed
ASC Owner or Partner
Other
How many years have you been in practice?
Which of the following tracks do you feel most confident mentoring 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
Are you currently involved in any formal mentoring program?
Yes
No
Preferences & Logistics
Are you open to mentoring:
One individual mentee
A small group (2-4 mentees)
Either is fine
Would you prefer to mentor someone in your:
Geographic region
Subspecialty or focus area
Career stage (e.g. early vs. mid-career)
No preference
How do you prefer to engage with mentees?
Email
Zoom/video chat
Phone calls
In person when possible
Asynchronous message board (e.g. Slack, Circle, etc.)
How often could you realistically connect with your mentee(s)
Monthly
Every 6 weeks
Quarterly
As needed
What is your preferred communication style?
Structured goals and timelines
Open-ended and mentee-driven
Combination of both
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