GPA Mentee Application Form

Thank you for your interest in being a mentee for the Georgia Psychological Association 1-1 Mentorship Program! 


The information you provide below will facilitate the best possible mentor/mentee match and ensure that the prerequisites for becoming a mentor have been met. Generally, the membership committee will keep the information you provide private; however, following a match, we will give your mentor your name.

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First Name *
Last Name *
Degree *
Current Home Address (City, State, and Zip Code) *
Primary Phone Number *
Other Phone Number 
Preferred Email Address *
Best Contact Method *
Are you currently licensed in GA? *
License Number:  *
If you are a graduate student, please list what year you are in your program 
Are you currently a GPA member?  *
Current Work Address (City, State, and Zip Code). If you are a student, please list the name of your graduate program.  *
Experience Level (years since earning your doctorate) 
 *
Areas of professional experiences that you are interested in receiving mentorship (check all that apply) *
Required
Settings that you are interested in receiving mentorship (check all that apply)  *
Required
Areas of treatment orientation, interventions, and approaches that you are interested in receiving mentorship (check all that apply) *
Required
Are you interested in receiving mentorship in these additional topics? (check all that apply)  *
Required
Additional Match Considerations (optional) 

If you are interested in being matched based on gender, ethnicity, sexual orientation, spiritual/religious background or other aspects of culture/identity, then please provide the information below. Note: This information is not required and matches based on this information are not always possible. 

Gender
Race and Ethnicity
Sexual Orientation 
Spiritual/Religious Background
Please provide any other information that you feel it is important for the membership committee to know about you as it relates to being a potential mentee. 
Please list any questions you would like to ask the membership committee regarding the program below. A representative from the committee will review your question and respond to your preferred email in a timely fashion.
By signing below (type first and last name), I attest that I have reviewed and agree to the terms of The Georgia Psychological Association Mentoring Program. I also attest that I have answered the above questions honestly and consent to the use of this information for purposes of participating in program. I understand that, once matched, I will make a one-year commitment to the program, including completing the yearly program evaluation.
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