Mentorshoppe – Mentee Application | APA Division 42 Psychologists in Independent Practice

Required Information

Name*

First and Last Name Please

Date of Birth*

Click calendar and the date picker will open.

Email Address*

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Graduate School*

City and State of Graduate School*

City State / Province / Region

Current Year in School (Check all that apply):*

Not Applicable
1 - 5
More than 5
Intern

Date Degree Received (if applicable)

If you have received your degree, please select the month and year you received it.

Month

Year

Not Applicable

N/A

Type of Degree Received or in Progress*

PhD
PsyD
EdD

If Applicable

Internship Training Site:

Internship Training Dates:

Internship Training City/State

Post-Doctoral Training Site:

Post-Doctoral Training Dates:

Post-Doctoral Training City/State:

Areas of Clinical Specialization (Check all that apply):

Other

Current work setting(s) (if applicable):

Institutional (Hospital, University, Clinic)
Independent Practice

Other

Briefly describe your current work setting (if applicable):

Optional Information:

Gender

Ethnicity

Sexual Orientation

Religious/Spiritual Affiliation

Mentor Preference:

Early Career Psychologist (ECP; 10 years or less post-graduation)
Mid-Career Psychologist
Senior Psychologist
Doesn't Matter

Mentoring Priorities (Click and drag to rank from highest to lowest):

Career advancement
Marketing
Business of practice
Professional identity development
Leadership development
Work-life balance

What specific goals would you like to address?

What other factors should we take into consideration in order to create a constructive match? Please review the list below and, based on your stated factors, preferences, and available mentors, drag the choices below into the order of preference - with the first being your most important. If you do not have a preference please skip to the Agreement section below.

Other Matchup Factors (Click and drag to rank from highest to lowest in order of importance):

Mentor lives in same geographic region
Mentor shares the same sexual orientation
Mentor shares the same ethnicity
Mentor shares the same gender
Mentor shares the same religious/spiritual affiliation

Where did you hear about Mentorshoppe?*

Division 42 Website
Division 42 Listserv
Division 42 Independent Practitioner
APA Monitor
Colleague

Agreement

By typing my name and today’s date in the fields below and clicking submit, I acknowledge that I have read and that I agree to Division 42’s S/ECP Mentorshoppe Policies and Procedures.

Signature*

Date of Signing*

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S/ECP Mentee Application 2020

Required Information

Date Degree Received (if applicable)

If Applicable

Optional Information:

Agreement