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PBI Mentor Application
Thank you for your interest in being a part of our mentorship pool for the Pro Bono Incubator (PBI). We request that you fill out this short survey for us to gain some background knowledge about your areas of current/previous experience. Our goal is to utilize this information to best pair mentors and mentees to create successful partnerships.
Once your application is received, we will reach out to you within 1 week with further information. Our goal is to create a core group of mentors to best meet the needs of our mentees.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Current Affiliated Organization(s)
*
Please share current pro bono programs affiliated with and/or current work affiliations.
Your answer
What is your current role affiliation?
*
Choose
Pro Bono Program or Clinic Leader
Physical Therapist/PTA
Occupational Therapist/OTA
Speech Language Pathologist/SLPA
Other Healthcare Professional
Student ~ PT/PTA
Student ~ OT/OTA
Student ~ SLP/SLPA
Other Healthcare Student
Educator
Researcher
Other
Current/previous practice areas (Select all that apply)
*
Outpatient
Acute Care
Acute Rehab
Skilled Nursing Facility
LTACH
Home Health
Pediatrics
Other:
Required
Years of experience in pro bono/nonprofit setting.
*
Your answer
Types of pro bono experience (select all that apply)
*
Student-run clinic
Faculty-run clinic
Multi-disciplinary clinic
Starting a new clinic
Community/population health
Other:
Required
Do you have experience with...? (Select all that apply)
*
Clinic/program finances
Scheduling
Translation services
Clinic management
Program management
Program development
Outcomes
Community outreach
Referrals
Other:
Required
Geographic Region
*
Northeast (ME, VT, NH, MA, RI, CT, PA, NY, NJ)
Southeast (MD, DE, DC, VA, WV, NC, SC, GA, FL, AL, MS, LA, AR, TN, KY)
Midwest (OH, MI, IN, WI, IL, MO, IA, MN, ND, SD, NE, KS)
West (MT, WY, CO, ID, UT, WA, OR, CA, NV, AK, HI )
Southwest (AZ, NM, TX, OK)
Environment
*
Surburban
Urban
Rural
Is there anything you would like to share that you feel is relevant and was not covered by the rest of the application?
Your answer
Send me a copy of my responses.
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