Division 29 of the American Psychological Association

DIVISION 29 MEMBER - MENTOR SURVEY

The Division of Psychotherapy Student Development Committee is creating a web-based, members only mentor-protégé database.  The goal of this database is to allow students to contact professional members of Division 29 to ask advice, obtain referrals for personal therapy, receive guidance, and secure encouragement as they develop into professional members of Division 29.  

About You:
Name:
Gender:
  Male  Female
Ethnicity:
Email address:
Telephone:
Fax:
The County and State you are located in:
Academic Degree Held:
Year graduated with your degree:

Would You Be Willing to Mentor a Division 29 Student Member?
select:
If Yes, please describe the capacity in which you would be willing to get involved and the time comittment you envision being able to offer:

Where Are You Employed:
check ALL that apply
Private Practice
A Medical Center
An Academic Institution
A Business Setting
A Military Setting
Public Service
Other: 

Are you Actively Involved in Research?
select:
If YES, please provide a brief description of your research interests (goals of your research, type of participant, opportunities for student participation, etc.):

What Would You Consider to be Your Area of Expertise in Academia, Research, Practice or Training?

Do You Supervise Students in any Capacity?
select:
If YES, please provide a brief description of the capacity in which you supervise students:

Is there Any Other Information you Would Like to Share With Us?
On behalf of the Division 29 Student Development Committee, I would like to thank you for your time and cooperation.

Sincerely,
Adam Leventhal, Chair
Student Development Committee
Division 29, APA
Adam.Leventhal@mail.uh.edu