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ACLP Trainee/ECP Mentorship Signup 2024

Thank you for your interest in the ACLP resident Trainee & ECP Mentorship Program. The following questions will help us understand your interest in Consultation-Liaison Psychiatry and mentorship needs in order to match you with the best mentor. The deadline to apply for this year's program is September 30.

1. Your contact details

	First Name
	Last Name
	Credentials (MD, PhD, etc.)
	Current Academic Institution
	Preferred Phone Number
	Email
	Most recent training Program

2. Geographic Region *This question is required.

3. For Medical Students and Residents Only: Previous CL Rotation completed (Check all that apply)

4. Current Discipline/Position (Academic Year 2024-2025)

5. Are you a current member of the Academy of Consultation-Liaison Psychiatry? *This question is required.

6. Have you ever participated in the mentorship program in a previous year *This question is required.

If applying to this mentorship program for a 2nd year, please specify reason for doing so and what you would like to gain from the additional year.

7. Have you ever participated in a formal mentorship program before? *This question is required.

8. Areas of Interest (check all that apply) *This question is required.

Clinical sub-options

9. I am looking for mentorship in the following areas (check all that apply):

10. Please describe your career goals as they relate to CL psychiatry and describe how the mentorship program will help you to achieve them.

11. Please use this space to provide more information about what you are specifically looking for in terms of mentorship.

12. If there an important aspect of your personal background or identity or a commitment to a particular community that you would like to share to help align those interests with a potential mentor, we invite you to do so here. Aspects might include, but are not limited to living with a disability, socioeconomic factors, immigration or military status, or identification with a culture, religion, race, ethnicity, sexual orientation, or gender identity. Completing this section is entirely optional (use as many lines as needed).

13. Please attest to fulfilling the expectations of the program if selected: