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Thank you for your interest in the Association of Medicine and Psychiatry’s mentorship program! This template is designed to collect the information of those individuals who are SEEKING A MENTOR to discuss stages of career, development, advantages of combined training or practice.

First Name *

Middle Name

Last Name *

Email *

Phone *

Training Level Mentee

Medical student, 1st year Medical student, 2nd year Medical student, 3rd year Medical student, 4th year Resident, 1st year Resident, 2nd year Resident, 3rd year Resident, 4th year Resident, 5th year Early career physician Other (Specify below)

Training Level (Other)

What type of training program are you interested/enrolled in?

Training Program

FM/Psych

IM/Psych

Psych/Neuro

Triple board: psych/peds/child psych

Other (Specify Below)

Training Program (Other)

If you are a medical student, what is your medical school?

Medical School

If you are a resident, what program are you in?

Resident Program

If you are an ECP, what kind of practice do you currently have?

ECP

I prefer my mentor have a practice in...

Preferred Mentor Practice

Private Practice

Academics

Community Medicine/Psychiatry

Government

Other (Specify Below)

Preferred Mentor Practice (Other)

I prefer a mentor trained in...

Preferred Mentor Training

FM/Psych

IM/Psych

Psych/Neuro

Triple board: psych/peds/child psych

Other (Specify Below)

Preferred Mentor Training (Other)

Any Special Interests

Date

Due to the high demand of combined trained mentors, we'd like to be sure that all mentees can commit to contacting their mentor four times during the academic year. Is this something that you can commit to? *

Yes No

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