UPSIDE Mentor Questionnaire
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1.
Name
(Required.)
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2.
What is your gender identity?
(Required.)
Man
Woman
Non-binary
Other (please specify)
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3.
What is your preferred e-mail address?
(Required.)
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4.
What is your preferred phone number?
(Required.)
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5.
What is your current City, State?
(Required.)
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6.
What type of degree do you hold?
(Required.)
Ph.D.
Psy.D.
Ed.D.
Other (please specify)
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7.
From which program did you receive your doctoral degree?
(Required.)
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8.
Please identify your area(s) of specialization
(Required.)
Clinical Psychology (adolescent/adult)
Clinical Psychology (child)
Clinical Psychology (older adults)
Clinical Neuropsychology
Counseling Psychology
School Psychology
Other (please specify)
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9.
What is the name of your primary work setting (e.g., hospital, your private practice, etc.)?
(Required.)
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10.
Which underrepresented students in psychology do you wish to mentor? (check as many as apply)
(Required.)
Asian or Asian American or Pacific Islander
Black
Hispanic or Latinx
International
LGBTQ+
Muslim
North African or Middle Eastern
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
Orthodox Jewish
Socioeconomically Disadvantaged
Students with Disabilities
Other (please specify)
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11.
Please describe your clinical/research interests, areas of expertise, and/or special populations with whom you work.
(Required.)
12.
What is the maximum number of mentees you wish to work with at one time?
13.
How do you wish to provide mentoring? (check all that apply)
In Person
By Phone
By E-mail
By Video Chat
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14.
What is your availability for mentoring?
(Required.)
A one-time consultation
Weekly contact
Monthly contact
Other (please specify)
15.
Is there anything else you would like to add regarding your role as a mentor?
