ASPP Mentee Application
Application for 2016-2017 ASPP Mentoring Program
Contact Information
Name:
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Phone Number:
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Email Address:
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Mailing Address:
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Degree Information
Granting Institution (or current institution):
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Year Graduated:
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Type of Degree:
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Licensure/Credential:
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Additional Information
Agency/type of practice (please describe the work that you do):
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Do you have a specialization or particular area of interest? If so, please describe:
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What piqued your interest in having a mentor? How are you hoping to be helped by mentoring?
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What might you want to focus on with your mentor?
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What led to your interest in psychoanalytic/psychodynamic thinking and/or its application to your clinical work?
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Location and Time Availability Preferences
Preferences for Location (check all that apply):
Required
Preferences for Meeting Times (please include any specific day/time preferences under "Other..."):
Required
Are you able to attend at least one ASPP Monthly Meeting in the Fall and Spring?
Are you already a member of ASPP?
Other Questions:
Please share with us any other factors you’d like us to consider when matching you with a mentor (such as age, culture/ethnicity, area of expertise, mobility restrictions, etc.)
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How did you hear about the ASPP Mentoring Program?
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