UPSIDE Mentor Questionnaire Question Title * 1. Name Question Title * 2. What is your gender identity? Man Woman Non-binary 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 type of degree do you hold? Ph.D. Psy.D. Ed.D. Other (please specify) Question Title * 7. From which program did you receive your doctoral degree? Question Title * 8. Please identify your 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. What is the name of your primary work setting (e.g., hospital, your private practice, etc.)? Question Title * 10. Which underrepresented students in psychology do you wish to mentor? (check as many 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, areas of expertise, and/or special populations with whom you work. Question Title * 12. What is the maximum number of mentees you wish to work with at one time? Question Title * 13. How do you wish to provide mentoring? (check all that apply) In Person By Phone By E-mail By Video Chat Question Title * 14. What is your availability for mentoring? A one-time consultation Weekly contact Monthly contact Other (please specify) Question Title * 15. Is there anything else you would like to add regarding your role as a mentor? Done
