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LGBTQ+ CSDSA Mentorship Questionnaire
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Name and pronouns:
Your answer
School name and program:
Your answer
Email or other preferred method of contact:
Your answer
Previous participation:
I previously participated in the LGBTQ+ CSDSA program.
I have not participated in the LGBTQ+ CSDSA program.
Clear selection
Please indicate how you relate to the LGBTQ+ community.
I identify as part of the LGBTQ+ community
I identify as an ally to the LGBTQ+ community
Other:
Please indicate when you are available to start the mentorship program.
MM
/
DD
/
YYYY
Professional interest:
Audiology
Speech Language Pathology
Other:
Clear selection
Special areas of interest within your field of study (e.g. language development, language disorders, bilingualism, AAC, pediatrics, gender affirming services, etc.)
Your answer
Which activities would you like to participate in? (Check all that apply.)
Informal conversations with mentor through video conferencing/email
Integration into a mentor's lab or clinic
Joining a mentor's lab meeting or journal club
Assistance in networking
Other:
Questions or comments? Please write them here:
Your answer
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