UPSIDE Mentor Request Form Question Title * 1. Name Question Title * 2. What is your gender identity? Man Woman Non-binary Prefer not to answer Other (please specify) Question Title * 3. What is your preferred e-mail address? Question Title * 4. What is your preferred phone number? Question Title * 5. What is your current City, State? Question Title * 6. What is your current educational setting? Clinical/Counseling Psychology Ph.D. program Clinical/Counseling psychology Psy.D. program Psychology Master's program Undergraduate Psychology major Other (please specify) Question Title * 7. What is the name of the program you are attending? (optional) Question Title * 8. Please identify your desired area(s) of specialization Clinical Psychology (adolescent/adult) Clinical Psychology (child) Clinical Psychology (older adults) Clinical Neuropsychology Counseling Psychology School Psychology Other (please specify) Question Title * 9. Which work settings appeal to you (e.g., hospital, college counseling center, military, forensic, private practice, etc.)? Question Title * 10. How are you an underrepresented psychology student? (check as many descriptors as apply) Asian or Asian American or Pacific Islander Black Hispanic or Latinx International LGBTQ+ Muslim North African or Middle Eastern Native American or Alaska Native Native Hawaiian or other Pacific Islander Orthodox Jewish Socioeconomically Disadvantaged Students with Disabilities Other (please specify) Question Title * 11. Please describe your clinical/research interests and/or special populations with whom you wish to work. Question Title * 12. How do you wish to receive mentoring? (check all that apply) In Person By Phone By E-mail By Video Chat Question Title * 13. What is your desired frequency of mentoring? A one-time consultation Weekly contact Monthly contact Other (please specify) Question Title * 14. Please describe briefly the goal you wish to achieve through this mentoring opportunity. Done
