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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 WANT TO BE A MENTOR to physicians, trainees or students in a lower-seniority phase of career.

First Name *

Middle Name

Last Name *

Email *

Phone *

Training Level

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

Training Level (Other)

What type of training program are you enrolled in/graduated from?

Training Program

FM/Psych

IM/Psych

Psych/Neuro

Triple board: psych/peds/child psych

Other (Specify Below)

Training Program (Other)

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

Resident Program

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

ECP

My practice is predominately...

Private Practice

Academics

Community Medicine/Psychiatry

Government

Other (Specify Below)

(Other)

Any Special Interests

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