Thank you for your interest in becoming a mentee within the Collaborative Mentorship Network for Chronic Pain and Addiction (CMN). We look forward to connecting and assisting you to care for patients struggling with chronic pain and/or substance use disorder.

This survey helps us to collect information about you in order to successfully match you with a potential mentor.

Thank you for taking the time to fill out this survey.

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* 1. Name:

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* 2. Preferred email address:

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* 3. Please articulate the top 3 areas in which you would like mentorship in bullet point form (the more specific you are, the better we will be able to match you with a mentor that can support your needs):

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* 4. Please describe your work setting/clinic (location, type of clinic, common patient populations etc.):

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* 5. Is there anything unique about your practice or history you would like us to know?

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* 6. Do you have the flexibility in your schedule to connect with a mentor and follow up when mutually convenient?

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* 7. Do you have any requests for upcoming CME/CPD topics?

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