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Mentoring Program--Mentor Form

(All information listed below--except for "Address [cont.]"--is required.)

1.  Please provide the following contact information:

First Name            
Last Name            
Degree            
Job Title            
Facility            
VISN            
Street Address            
Address (cont.)  
City            
State            
ZIP Code            
Work Phone            
FAX  
E-mail            


2. Describe Briefly Your Current Position in VA and Duties:

 
 

3. Please Choose One “Track” that Suits Your Talents. What kind of “Protégé” would you feel most qualified to counsel?

Early Career – Psychologists with 5 years of employment or less with VA who are looking at making a next step to team leader, first line supervisor, or program official with responsibilities in addition to beyond a solely direct service or provider role.

Academic/Research Career – Psychologists who are clinical researchers seeking to develop and define their role as an independent investigator, with or without clinical service or teaching responsibilities.

Mid-Career – Psychologists who are currently in positions of leadership or responsibility, but who are looking to assume senior professional and/or managerial roles in VA.


Completing this form is an expression of interest and does not bind or commit you to any course of action or participation. The Mentorship Program is being established for a one year period for new enrollees is intended and designed for AVAPL Members. The program provides for some Mentorship Training and is intended to be an activity that will be easily encompassed within current duties.