Become a Mentor!

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* 1. Your Name: 

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* 2. Your Email:

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* 3. What is your discipline?

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* 4. Please indicate your primary areas of expertise in Psychosocial Oncology: (please select all that apply)

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* 5. Please check all topics that you would like to discuss with your mentee(s):

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* 6. Do you have a specific project or an initiative that you would like to have mentee support to advance?

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* 7. Would you like your special project or initiative to be considered in the mentee matching process?

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* 8. How many mentees would you be interested in having?

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* 9. How frequently would you like to correspond with your mentee(s):

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* 10. What is your preferred method of correspondence with your mentee(s): (in addition to an in person contact during the annual meeting)?

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* 11. Please rate the criteria, based on personal importance, by which you would like to be matched with your mentee(s):

  1 (being the highest priority) 2 3 4 (being the lowest priority)
Professional discipline
Career interests (e.g., clinical work, spirituality, etc.)
Research interests
Preferred method of correspondence

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* 12. If you have other criteria that is exceptionally important to you that is not listed in question #9, please add and rate them here:

  1 (being the highest priority) 2 3 (being the lowest priority)
Additional Criteria 1:
Additional Criteria 2:
Additional Criteria 3:

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* 13. Is there anything additional you would like to share about a potential mentoring experience?

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* 14. Please provide a 2-3 sentence bio about yourself, your daily work environment, including research interest, and anything else you think might be useful in matching you with a mentee. (optional)

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