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DCPA Mentorship Program Mentor/Mentee Application
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* Indicates required question
Email
*
Your email
1. Name
*
Your answer
2. Demographics (optional)
Your answer
Gender
Your answer
Race/Ethnicity
Your answer
Sexual Orientation
Your answer
Religion
Your answer
Other
Your answer
4. Telephone Number
Your answer
5. Position applying for:
*
Mentor
Mentee
Both
Required
6. Professional Background: Please indicate your current career level:
*
Undergraduate Students
Graduate Students
Postdoctoral resident/fellow
Early Career
Mid Career
Advanced Career
Required
7. List Degrees obtained -Add years to your answer
*
Your answer
8. Licensure Status (If Applicable)
License - eligible
Licensed (See question 9)
9. Licensed (Add State and Year below)
Your answer
10. For mentors only, describe your current position:
Your answer
11. Describe your primary clinical/research interests
Your answer
12. Mentoring Interests - For which of the following training levels would you like to provide mentorship (select all that apply)?
Undergraduate students
Graduate students
Predoctoral interns
Postdoctoral resident/fellows
Early Career
Mid Career
Advanced Career
13. For which of the following topics would you like to provide/receive mentorship (select all that apply)?
Preparing for Graduate School
Preparing for Internship/Post-doc
Clinical Skills
Career Planning/Professional Development
Diversity variables (i.e., race, sex, disability, sexual orientation, religion, other)
General Support/Work-Life Balance
Teaching/Supervision/Training
Research/Grants/Publications
Leadership
14. For mentors, how many mentees would you like to be paired with?
Your answer
15. How often would you like to meet with your mentee(s)?
Twice per month
Once per month
Quarterly
Semi-annually
Other (see question 16)
16. If you chose other in question 15, please specify:
Your answer
17. Ideally, how would you prefer to meet with your mentor/mentee(s)?
In-person
Teleconference (e.g., phone/video)
18. Do you have any preference for being matched with a mentor/mentee of any specific identities (e.g., gender, sexual orientation, race/ethnicity, religion)? If so, please list the specific identity.
Your answer
19. Have you been a mentee before?
Your answer
20. For mentors only, what are your strengths as a mentor?
Your answer
21. What would mentorship look like for you?
Your answer
22. What are your hobbies/interests outside of psychology?
Your answer
A copy of your responses will be emailed to the address you provided.
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