*1.Contact Information(Required.)

First Name, Last Name 

Email

Phone

Practice/Affiliation

Title

Years of Experience in REI

*2.Would you like to be a mentor or mentee?(Required.)

Mentor

Mentee

*3.Check areas of interest and/or expertise.(Required.)

 Clinical Operations/Management

 Third Party Management

 Clinical Skills in a REI Setting

 Empathy Fatigue

 Communication skills (Patients & Colleagues)

 Ethical and Legal Considerations

 Critical Thinking and Problem-solving

 Patient Education and Expectations

 Professional Development

 Onboarding to the field of REI

 Non-ART vs. ART

Other (please specify)

*4.NPG will hold the first NPG Mentorship Program in-person meet and greet at the ARM&NPG meeting in April. Will you be attending?(Required.)

Yes

No