AADPRT TD Mentor Form

AADPRT Training Director Mentorship Program Interest Form

We're excited you're interested in connecting with other AADPRT members to develop a fruitful mentorship experience! Mentors and mentees can work together to discuss career development, troubleshoot workplace politics, brainstorm practical work/life strategies, or just about anything else. Take a moment to answer a few questions below which can help us match you with the right mentor or mentee.

Recommended Experience to be a Mentor: Asst/Assoc Training Director - at least 2-3 years; Training Director - at least 5 years

Isheeta Zalpuri, MD
Chair, Mentorship Committee

Name*

First Name

Last Name

Institution/University/Organization*

City/State*

City

State

Phone (must include valid area code)*

Email*

Confirm Email *

Program Type*

General Psychiatry Residency Child and Adolescent Psychiatry Fellowship Triple Board Consultation-Liaison Psychiatry Fellowship Addiction Psychiatry Fellowship Forensic Psychiatry Fellowship Geriatric Psychiatry Fellowship

Other:

Current Position*

Training Director Assistant/Associate Training Director Director of Psychotherapy Training Division Chief Chair Vice Chair/Director of Education/Academics Chair Dean or Assistant/Associate Dean

Other:

Number of Years in Current Position*

Number of Years in Educational Leadership (i.e. any of above roles)*

I'm Interested in Being a*

Mentor Mentee Both

RECOMMENDED EXPERIENCE TO BE A MENTOR: Asst/Assoc Training Director - at least 2-3 years; Training Director - at least 5 years

Mentor Information

To best help us identify an appropriate mentee for you, please fill out the below information. If you are an Assistant or Associate Training Director, we recommend that you have had at least 2-3 years In the position before becoming a mentor. If you are a Training Director, we recommend that you have had at least 5 years in the position before signing up to be a mentor.

Please indicate the maximum number of mentees you would be willing, able, and interested in working with in a 1:1 mentorship relationship.*

Would you be interested in mentoring a group of mentees interested in exploring a specific topic from the list below? (If interested in a particular topic, please list in Other)*

Yes No

Is there anything else you could tell us about you that may help us pair you with the right mentee (e.g. particular interest, background, life experience)?

Mentee Information

To best help us identify an appropriate mentor for you, please complete the below information.

Gender Preference*

Female Male No preference

In what Career Stage do you prefer your mentor to be? (check all that apply)*

Early (3-5 years) Mid (6-10 years) Lifer (11+ years)

Time Zone Preference*

Eastern Central Mountain Pacific Alaska Hawaii No preference

Diversity/Inclusion Preference (check all that apply)*

Underrepresented Minority (please specify below) LGBTQ IMG

Other:

Underrepresented Minority Description*

Position/Role Preference*

Training Director Assistant/Associate Training Director Vice Chair/Director of Education

Other:

Preferred Contact Frequency*

Monthly At AADPRT and/or other meetings No preference - whatever happens is fine

Other:

Are you interested in group (like-minded mentees paired with a mentor based on particular theme/task) or peer (like-minded mentees working with and mentoring each other on particular theme/task) mentoring?*

Group Peer Both None

Is there anything else you would like to tell us about you that may help us pair you with the right mentor (e.g. particular interest, background, life experience)?

Thank you!

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