2024-2025 SWHPN Mentor Application

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Hello!

Thank you for your interest in being a mentor for a SWHPN member!

Here is general information about the mentorship program:

1. This is a one year commitment which will complete at the next SWHPN Conference in 2025.

2. The primary mode of communication will be email and phone contact (or zoom if preferred).

3. Expectations include quarterly phone call and monthly emails.

4. Each mentor and mentee pair will work together to define the goals for their mentorship year.

5. The mentorship program is for professional growth and support.

This program is not intended to be used for clinical supervision.

Please answer the questions in this form to help us learn more about you so we can pair you with a good fit.

Thanks for your interest!

Team SWHPN

Name *

Email (that you would want to use with your Mentee) *

Phone number *

Are you a current SWHPN member? *

Yes

Other:

What time zone do you reside in? *

EST (Eastern Standard Time)

CST (Central Standard Time)

MST (Mountain Standard Time)

PST (Pacific Standard Time)

Other:

Are you currently in practice? *

Yes

Other:

What type of organization do you work in? *

Acute Care Hospital

Home Hospice Agency

Inpatient Hospice

Community Organization

Academic Institution

Palliative Care Agency (Home Care)

VA (inpatient or outpatient)

Outpatient Clinic

Other:

Please share if you work primarily in an inpatient or outpatient setting *

Mostly inpatient

Mostly outpatient

Mix of both

Other:

Where do you work (name of agency, hospital, school etc)?
*

What city and state do you work in? *

What is the primary focus of your work? *

Palliative

Hospice

Academics

Research

Other:

How long have you worked in your current field of practice *

Less than 1 year

1 to 3 years

4 to 6 years

7 to 10 years

Over 10 years

How long have you worked as a social worker? *

Less than 5 years

5 to 10 years

10 to 15 years

15 to 20 years

Over 20 years

Please share what licensure you have *

What topics would you like to discuss with your mentee? *

Patient care

Academic activity

Career advancement

Research

Teaching

Leadership skills

Networking

Program Development

Work/life balance

Self Care

Required

Mentees are usually matched to a mentor by the focus of their work. What other areas would you like to be matched by, if any?

Can you commit to be available for monthly phone calls and emails with your mentee? *

Yes

Maybe

In general, when do you anticipate being available to have conversations with your mentee? *

Weekdays

Weekends

Evenings

I can be flexible

Other:

Required

What do you hope to offer to your mentee? *

What do you hope to get out of being a SWHPN mentor? *

Is there anything else you'd like us to know?

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