APA Division 17: SOCIETY FOR COUNSELING PSYCHOLOGY
Section on Ethnic and Racial Diversity (SERD)
Mentee/Request for Mentor Form
NAME:______________________________________________________________________________________
Title
(Dr./Mr./Mrs./Ms.) First Middle
Last
HOME
ADDRESS:____________________________________________________________________________
CITY: ___________________________________ STATE:_______________
ZIPCODE:_____________
HOME PHONE: ________________ BUSINESS PHONE: ___________________
E-MAIL: __________________________________________
THE BEST TIMES TO REACH ME ARE:
Mornings ____ Afternoons ____ Evenings ______ Weekends ______ Other Times ______
STATUS: Student _____ Early Career Faculty _____ Early Career Clinician ______
SCHOOL/SITE:____________________________________________________________________________________
MAJOR/FIELD:_______________________________________________________________________________
PROFESSIONAL/RESEARCH/CLINICAL AREA OF INTEREST: ______________________________________________________________________________________
______________________________________________________________________________________
PLEASE CHECK ONE OF
THE FOLLOWING:
I would like to be mentored by a:
faculty (for students) _____tenured faculty (for early career faculty)
____career clinician (for early career clinicians)
Mentor PREFERENCES (Please check all that apply):
Male: ___ Female: ____
Private Practice: _____ Professor: ____ Psychiatric Facility: _____ Other: ______________
Specific School/Type of Clinical Setting: _________________________________
Geographic Location: ________________________________________________________________
Other: ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
My areas of interest/expertise are:
___women issues ___body image concerns
___men issues ___eating disorders
___depression ___identity development
___anxiety ___group work
___race/culture/ethnicity ____relationship counseling
___spirituality ____vocational assessment
___ other _________________________________________
___ other_________________________________________
___ other _________________________________________
Please return this form to any of the following:
Laurie McCubbin,
Committee Co-Chair
Email:
mccubbin@wsu.edu
Assistant Professor
Educational Leadership and Counseling Psychology
Washington State University
PO Box 642136
Pullman, WA 99164-2136
Office (509) 335-2816
Fax (509) 335-6961
Ezemenari Obasi,
M.A., Mentor Committee Co-Chair
Email:
obasi.2@osu.edu
Doctoral Candidate
The Ohio State University
Department of Psychology
101 Townshend Hall
1885 Neil Avenue Mall
Columbus, OH 43210
Vivian
Barnette, Committee Co-Chair
Email:
vivian-barnette@uiowa.edu
Senior Staff Psychologist
The University of Iowa Counseling Service
3223 Westlawn
Iowa City, Iowa 52242-1100
Office (319) 335-7294
Fax (319) 335-7298