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SSWLHC Mentorship Program Application
The Mentorship Program provides members the opportunity to learn from other social work leaders and clinicians in health care or to serve as a mentor to colleagues developing their leadership skills. The Program creates the foundation for a meaningful mentoring experience by fostering an intentional and purposeful relationship guided by clearly-defined goals.

Unlike clinical supervision, the mentor/mentee relationship is centered on and guided by specific deliverables and goals. Mentees may choose to utilize their mentors for guidance and consultation toward the completion of a project (deliverable), or may identify goals related to more global skill development. Deliverables are intended to encompass and develop core leadership skills such as navigating professional dilemmas, strategic planning, or staff development, to name just a few.

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First and Last Name: *
City and State: *
Phone: *
Email: *
Current Position/Title: *
Current Employer: *
Years in Position: *
Years in Profession *
Please upload your resume: *
Required
Please briefly describe why you want to become a Mentor/Mentee: *
Please briefly describe what types of skills you would like to develop or guide others to develop as part of the Mentorship Program:
What do you hope to gain from this experience? *
Educational Background: *
Employment History: *
Committees/activities: *
Please indicate which of the core program areas you wish to explore as the basis for a mentoring relationship: *
Required
I confirm that the information provided in this application is true to the best of my knowledge and that I have read and understand the program description and its requirements. I understand that the submission of this application does not guarantee my participation in the SSWLHC Mentorship Program and, if accepted, I may be placed on a wait list based upon availability of resources at the time of application.I also hereby agree to hold harmless and indemnify the Society for Social Work Leadership in Health Care, its officers, agents and employees from any and all liability, loss, damages, costs or expenses which are sustained or incurred in connection with or in the course of the Mentorship Program. By indicating your full name below, you are completing an electronic signature agreeing to the statement above. *
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