PPTA is committed to launch its proposed mentoring program early this spring. In order to be successful and meet member needs, we need your input!

The program will establish an online forum through GoToWebinar where individuals will invest in a community group of mentors and mentees. We need mentors who can connect with and inspire mentees, and mentees to connect with learn and be inspired with their the mentors. We need to identify topics of mutual interest and need!

Please take a few moments to complete this survey so that we can plan our inaugural sessions, match mentors and mentees, and launch this program.

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* Please input your full name:

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* Please Input Your Email Address:

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* If a Mentor, Please Input Specialty:

Check all the boxes that are applicable:

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* Clinical Topics:

  I am interested in being a Mentor I am interested in being a Mentee
Acute Care
Cardiovascular/Cardiopulmonary
Geriatrics
Hand
Neurology
Pediatrics
Orthopedics/Manual Therapy
Sport PT
Women's Health
Wound Care
Other (Specify Below)

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* Comments:

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* Practice Settings/Administrative Focus:

  I am interested in being a Mentor I am interested in being a Mentee
Acute Care
Industrial PT
Long Term care/ Skilled Nursing
Pediatrics (Early Intervention, School-based, etc.)
Private Practice/ Outpatient
Rehabilitation
Women's Health
Other (Please Specify Below)

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* Comments

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* Leadership (PPTA involvement, including Chapter, Districts, SIGs):

  I am interested in being a Mentor I am interested in being a Mentee
Committee Service
District Leadership
Chapter Leadership
Membership/Connect PA/ Mentoring Program
Falls Prevention
PT Day of Service
Acute Care SIG
Pediatric SIG
Geriatric SIG
Neurology SIG
Physical Therapy Assistant SIG
Private Practice SIG
Other (Specify Below)

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* Comments:

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* Legislative/Health Policy/Ethics:

  I am interested in being a Mentor I am interested in being a Mentee
PPTA: Public Policy and Advocacy Committee
Legislative Ambassador Network
PA PT PAC
Federal Affairs
Ethics Committee
Other (Specify Below)

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* Comments:

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* Student Issues-PT PTA:

  I am interested in being a Mentor I am interested in being a Mentee
Surviving PT Schools
Transition from Academic courses to Clinical Education
Transition from Student to Professional
Involvement in APTA/PPTA, including APTA Student Assembly
Other (Specify Below)

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* Comments:

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* Miscellaneous:

  I am interested in being a Mentor I am interested in being a Mentee
Reimbursement (Insurance/Medicare/Medicaid)
Cash-based Practice
Education (Faculty Development; Adjunct Faculty opportunities)
Research (clinical research)
Clinical Practice Guidelines (use in clinical practice)
Patient Outcome Measures (use in clinical practice)
Other (Specify Below)

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* Comments:

Thank You For Your Time!

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