Mentee Application
Thank you for applying to be apart of NABC's Mentorship Program. Completion of this form will enable us to match each mentee to a mentor using data related to each person's interests, experience, career goals and professional development needs.
If you have any questions or concerns regarding the mentor program please feel free to contact the Mentorship Committee mentorship@nabcounselors.org
DEMOGRAPHICS
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Select the option that best describes the role you are most interested in pursuing
mentee
both mentor and mentee
BACKGROUND INFORMATION
What's the highest level of education you have had
Bachelor's Degree
Master's Degree
Doctoral Degree
Psyd
Ed.D
Other
Are you currently working in the mental health field?
YES
NO
If yes, what position do you currently hold?
How long have you been in the mental health field?
Do you hold any professional licenses or certifications? If so please list them below.
PREFERENCES
What are your preferred pronouns?
Please Select
She, her
her, his, him
they, them
Which meeting type do you prefer?
In Person
Virtually
Hybrid (in person or virtual)
What is your desired number of meetings per month with your mentor
1 time per month
2 times per month
Weekly
What is your preferred method of communication?
*
Email
Mobile Texts
Mail
Phone Calls
Do you have any preferences or qualities in your mentor?
*
Gender
Ethnicity
Age
Spirituality
Other
If you checked any box above please specify your preferences in the box below
MENTORING OUTCOMES
Select the mode of mentorship that best meets your current needs
One on One
Group or Team Based Mentorship
Subject Based Mentorship
Use the list below to identify areas you would like to either be mentored in or areas you are capable of mentoring others
*
Counselor Education
Career Development
Private Practice
Community Based Supports
Networking
School Counseling
Other
Which mentoring trait do you most identify with and or need?
*
Cheerleader : encourages and cheers the mentee on
Authoritative: challenges the mentee to achieve goals
Educator: provides education on specific skills, focus or professional guidelines
Networker: connects mentee with resources, people and/or organizations
Ideator: helps mentee in seeing the bigger picture and brainstorm ideas
What are your career goals and objectives?
What outcomes are you hoping to gain from being a mentee?
Back
Next
What makes you a good candidate for the mentorship program?
What gaps do you perceive are within your professional development and how can the mentorship program help you to address those gaps?
What makes you a good candidate for the mentorship program?
*
Submit
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