Mentoring Request Form
First Name:
Last Name:
E-mail Address:
Cell Phone Number:
Please select your license type:
Please select...
MD
DO
PA
NP
Other
If "Other", please describe:
What type of Mentoring are you interested in?
Clinical Mentoring
Leadership Mentoring
Clinical Mentoring focuses on topics such as patient care skills and time management. Leadership Mentoring focuses on topics like career progression, management skills, and non-clinical programs.
x
Which clinic are you affiliated with?
Title/Role At Your Current Organization:
Bio (Please tell us about your clinical background and interests):
Please select the type of mentor you are interested in?
Primary Care
Specialist
A primary care mentor are available to talk on a variety of cases and approaches for patients, and to help develop your professional skills. While a specialist mentor will focus on teaching you about their specialty.
Please indicate which specialty you are interested in.
You can find the list of volunteer specialties on VSee.
What topics would you like to cover as part of your
Clinical Mentoring
? (
select all that apply
):
Career Progression
Chronic Disease Management
Diagnostic Test Interpretation (e.g. Lab review, EKG review)
General Patient Care Skills
Improved Clinician-Patient Communication
Patient Case Reviews
Time Management
Work-Life Balance
Other
If "Other", please describe:
What topics would you like to cover as part of your
Leadership Mentoring
? (
select all that apply
):
Achieving short-term outcomes (e.g. specific change initiative, performance outcomes, etc.)
Being more comfortable in my role as a leader
Building a healthy team culture
Burnout/Compassion Fatigue
Career progression
Challenging relationships with peers, staff, or supervisors
Designing and achieving longer-term outcomes (e.g. clinic reorganization, changes in work design, opening a new unit/site, etc.)
Giving and receiving feedback
Managing diverse teams
Recruiting and retaining qualified staff
Work-life balance
Other
If "Other", please describe:
In your own words, what goals and objectives do you have for mentoring at this time?
Availability
Your Time Zone:
Please select...
Eastern
Central
Mountain
Arizona
Pacific
Please indicate the days of the week and times when you are available: (e.g. every Monday from 10:00am-12:00pm)
Monday
Tuesday
Wednesday
Thursday
Friday
7am - 8am
8am - 9am
9am - 10am
10am - 11am
11am - 12pm
12pm - 1pm
1pm - 2pm
2pm - 3pm
3pm - 4pm
4pm - 5pm
5pm - 6pm
6pm - 7pm
7pm - 8pm
How frequently would you ideally like to meet?
Please select...
Weekly
Bi-Weekly
Monthly
Every Other Month
Ad hoc (as needed only)
Please indicate how you learned about MAVEN Project mentoring?
Please select...
Discussed during an Education Session
During the onboarding process
From the Clinic Portal
Read in the monthly utilization email
Recommended by Clinic Leadership
Recommended by MAVEN Project Volunteer or staff member
Other
If "Other," please describe.
Please share the name of the volunteer or staff member.
Contact Information