<p> TEXAS PSYCHOLOGICAL ASSOCIATION’S PROFESSIONAL PRACTICE MENTORING PROGRAM</p><p>Undergraduate Student Mentee Application</p><p>The information that you provide below will be used to facilitate the best possible mentor/mentee match and to ensure that the prerequisites for becoming a mentee have been met. Please print or type this form, filling in all spaces completely, unless they are designated optional.</p><p>Name: ______Address: ______Phone: ______Fax:______E-Mail: ______Preferred Method of Contact: ______Anticipated Degree: □ B.A. □ B.S.</p><p>Anticipated Year of Graduation: ______</p><p>Undergraduate University: ______</p><p>Specialty: □ Behavioral □ Clinical □ Clinical Child □ Clinical Health □ Clinical Neuropsychology □ Counseling □ Family □ Forensic □ Industrial-Organizational □ Psychoanalytic □ School</p><p>Please list any Professional Affiliations and/or positions held (Psi Chi, TPA, CAPA, APA, etc.): ______</p><p>Would you like to be matched in terms of gender, ethnicity, sexual orientation, or spiritual orientation/preference? □ No □ Yes If yes, please indicate the gender, ethnicity, sexual orientation, and/or spiritual orientation/preference:</p><p>Gender (optional*): □ Female □ Male Ethnicity (optional*): ______Sexual Orientation (optional*): ______Spiritual Orientation/Preference (optional*): ______</p><p>*This information is only necessary if you would like to be matched in terms of gender, ethnicity, sexual orientation, or spiritual orientation/ preference. Matching of these variables is dependent on availability and cannot be guaranteed. TPA Mentee Application Page Two</p><p>If available, are you interested in a Tri-fold Mentoring Relationship, which would include 1 experienced psychologist mentor, 1 early career psychologist mentor/mentee, and 1 graduate or undergraduate student mentee? □ Yes □ No</p><p>Are you willing to enter into a long distance mentoring relationship? □ Yes □ No Desired time commitment/frequency of contact: ______Type of Practice: ______Area(s) of interest or specialization:______</p><p>Please prioritize any of the following area(s) that may be of interest to you in your mentoring relationship: □ Practical application of ethics □ How to be competitive in the job market □ Starting a small business (e.g., private practice) □ Research, areas: ______□ Marketing □ Life/professional goal setting □ Professional identity □ Reimbursement(e.g., insurance and billing) □ Organizing a psychology course □ Evaluation and application of personal strengths or talents □ Program development □ Personal liability, health, disability, office insurance □ Self awareness □ Business skills □ Interdisciplinary treatment teams □ Opportunities for observation by mentee □ Forms □ Joining a group practice □ Involvement with APA/TPA □ Transitioning from a group practice □ Other: ______</p><p>By signing below, I attest that I have answered the above questions honestly and consent to the use of this information for purposes of participating in The Texas Psychological Association’s Professional Practice Mentoring Program.</p><p>______Signature Date</p><p>Please email completed form to: [email protected]</p><p>Adopted from Ohio Psychological Association</p>