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ACLP Resident Mentorship Sign-up (mentee) 2023

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 *This question is required.

First Name
Last Name
Credentials (MD, PhD, etc.)
Name of your Psychiatry Residency Program
Preferred Phone Number
Email

2. Geographic Region *This question is required.

3. For Medical Students and Residents Only: Previous CL Rotation completed

4. Current Discipline/Position (Academic Year 2022-2023)

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

6. Did you participate in last year's mentorship program? *This question is required.

Please comment on your reasons for re-applying

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

Clinical sub-options

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

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

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

11. 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).

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