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Mentor Sign-Up

Please read all questions carefully and answer as completely as possible. Required information is marked with a red asterisk and must be completed in order for your application to be considered.

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Applicant
Ethnicity and Race
Mentor Information

Applicant

Applicant Information

First Name*

Last Name*

Email Address*

Phone Number*

Timezone*

Credentials*
Remaining 100 words out of 100

How many mentees are you willing to take on at once? *

Ethnicity and Race

Ethnicity*

Race*

If other, please specify race.

Mentor Information

Experience

Please select your area of focus:*

Severe mental illness

Opioid Use Disorder

HIV/AIDS

Depression

Trauma Informed Care

Mental Health Stigma

LGBTQ+ gender-affirming care

Intimate Partner Violence

Adverse Childhood Experiences (ACES)

Social Determinants of Health

Post Traumatic Stress Disorder (PTSD)

Substance Use Disorder

Homeless and mental health and/or substance use

Please describe your area(s) of research or practice. *
Remaining 350 words out of 350

What is your professional background and current role? *

What is your previous mentoring experience?
(Check all that apply)*

Research

Clinical Practice

Education

Leadership

Advocacy

Other

None

If other, please specify.

Which of the following areas would you like to provide mentoring for? (check all that apply) *

Career Development	Skill Development
Personal Development	Professional Growth
Entrepreneurship and Innovation	Cultural Competence
Academic Guidance	Performance Improvement

What is your preferred method of communication? *

EmailTextPhone callsZoom/ in person meetings

How frequently would you like to work with your mentor/mentee? *

Contact Us

American Nurses Association, SAMHSA Minority Fellowship Program
8403 Colesville Road
Silver Spring, MD 20910
Phone: 301.628.5247
Email: mfp@ana.org

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