Mentoring Application

Due to the number of qualified applicants who are sincerely committed to this work and our limited availability of time for high quality mentoring relationships, we must select only applicants we feel will benefit most from this association. Please understand that we support and appreciate your interest and regret that acceptance to this program must be restricted.

First Name

Last Name

Work Phone

Cell Phone

Leave blank if you prefer us not to call your cell

Are you a ... ?

Practicing clinician

Graduate student

How long in Practice?

How long with PPD clients?

What are you studying?

Date of Graduation?

Have you completed the PPSC Post-Graduate Advanced Training Program: The Art of Holding Perinatal Women in Distress?

Yes

Pending

Date of Graduation?

Please describe the impact the training has had on your work or your intentions to take the training

List any classes, seminars, workshops or training that you have completed that prepare you for particpation in this program?

What do you think makes you a good candidate for this program?

What personal goals do you hope to achieve through this program?

Is there anything else you would like us to know?

What is your primary reason for participating in the program?

First Reference

First Name

Phone

Last Name

Relationship

Second Reference

First Name

Phone

Last Name

Relationship

Please check if you agree *

I understand that all mentoring consultations are professional commitments and I agree to provide 24 hrs notice prior to any cancellation. Payment for consultations will be made in a timely fashion upon receipt of services, whether in person, phone, or virtual. If these conditions are not met, the PPSC reserves the right to discontinue mentoring sessions.

Please state that this information has been submitted by you and it is correct: *

I certify that the information on this application is accurate

Don't forget to read, sign and return the Mentoring Agreement.

Thank you! Applications are reviewed on a first-come, first-served basis. Once your application has been reviewed, you will be contacted regarding your acceptance status.