Mentor Application Form
Credentials: (degrees, licenses and certifications)
Full Name:
Town/City:
Areas of specialization and experience/populations worked with:
Number of years licensed:
Chapter member? 

Additional work site(s)
Work site: (agency, private practice, university, etc.)
Previous experience being a mentor?  If so, please explain:
Why do you want to be a mentor and what do you think you can offer a mentee?
Contact info:

 - Phone

 - Website

 - Email address
NYMHCA member #
What ways are you are willing to be in contact with a mentee? Check all that apply:

If yes, what NYMHCA chapter do you belong to?
Before submitting your application, please respond below:   (If you have not read the Mentoring Program Overview, click here.)
*After you submit your application, you will receive an email confirmation and will be asked to submit a CV by email.  When your application and CV have been reviewed, you will be notified regarding the status of your application.

Thank you for your interest in mentoring our future professionals!
Questions?  Concerns?
Contact Us
Phone
Text
In Person
Skype/Facetime
Email
Yes. I am a chapter member.
No. I am not a chapter member.
I have read the requirements to become a mentor and the roles and expectations of that role.
I have read the overview of the mentoring program and accept the responsibility to maintain confidentiality during the mentoring relationship.
I have read the guidelines regarding conflict resolution, grievance and relationship termination and accept those terms.
I understand that if accepted as a mentor, the information I have provided above will be posted on the NYMHCA website to be viewed by mentees.
I understand that before mentoring a mentee, I need to confirm the mentee's NYMHCA membership with the NYMHCA office.