Mentor Application Form
Complete this form if you are interested in participating as a mentor for the KPA Leadership Academy.
Contact Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Diversity Matrix
Diversity of Work Setting
Please Select
Independent Practice
Education
Science
Public Interest
State Employee
VA
Hospital/Academic Medical Center
Other (please specify)
Work Setting - Other:
Diversity of Career Stage
Please Select
Graduate Student
Early Career (0-10yrs)
Mid-Career (11-20yrs)
Late-Career (21+ years)
Geographic Diversity
Please Select
Louisville Area
Lexington Area
Eastern KY
Western KY
Other (please specify)
Demographic Diversity
Race/Ethnicity (specify)
Gender Identity
Sexual Orientation
Neurodiverse
Disability
Religion
Nationality
Other (please specify)
Demographic Diversity - Other:
Please include any additional details that you would like to share related to your demographic diversity.
Please include any areas of diversity with which you identify not included above
Mentor and Leadership Insights
Please provide brief answers to the following questions to help us match you with an ideal mentee:
Briefly describe your current role and leadership experience in psychology (and other fields, if applicable).
Have you mentored others before? If yes, describe your mentorship style and how you typically support mentees.
Are you able to commit to monthly contact with your mentee for the duration of the program? What is your preferred meeting format (virtual or in-person)?
How would you help your mentee apply the skills learned through "the Leadership Challenge"? Are you comfortable guiding them through a leadership-based project?
What kind of mentee would you be best suited to mentor (e.g., experience level, goals)? Why are you interested in participating as a mentor in this program?
Curriculum Vitae
Please upload a copy of your CV
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