APA Division 17:  SOCIETY FOR COUNSELING PSYCHOLOGY

Section on Ethnic and Racial Diversity (SERD)

 Mentor Membership Form

NAME: __________________________________________________________________________________

Title (Dr./Mr./Mrs./Ms.)     First                              Middle                                     Last

HOME ADDRESS:___________________________________________________________________

CITY: _______________________________________STATE:_______________

ZIP CODE:_____________

HOME PHONE: ________________ BUSINESS PHONE: ___________________

E-MAIL: __________________________________________

 

THE BEST TIMES TO REACH ME ARE:

Mornings ____ Afternoons ____ Evenings ______ Weekends ______ Other Time _______

 

STATUS: Faculty______Professional Clinician ____ Student ____

HIGHEST DEGREE EARNED: _________

 

PLACE OF EMPLOYMENT/SCHOOL/CLINICAL SETTING:

____________________________________________________________________________

JOB TITLE:

_____________________________________________________________________________

PLEASE ANSWER THE FOLLOWING:

 I am an APA Division 17: Professional Member _____ Graduate Student _____

 I would like to be a Mentor to a:

student ____ early career faculty ____ early career clinician____

 I would like to be a Mentor for the following number of mentees:

One___ Two ____ Three _____ (other amount) _____

My psychology-related field is:________________________________________________________________

My areas of specialty are: (Please check three)

 ___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 _________________________________________

 

Important notes about my role as a Mentor or Consultant / Type of student I can be of most help to:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Students

Early career (pretenure) faculty

Early career clinicians

 

Please return this form to any of the following committee members:

 

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:  ezemenari@obasi.org
McLean Hospital

Harvard Medical School

Behavioral Health Partial
115 Mill Street

Belmont, MA 02478-9106

Office: (617) 855-3915            Fax: (617) 855-3776

 

Vivian Barnette, Committee Co-Chair
email:  v_barnet@uncg.edu
Staff Psychologist
The University of North Carolina at Greensboro
Counseling and Testing Center
Gove Health Center Annex, 1605 Spring Garden Street
Greensboro, NC 27402-6170

Office:  (336) 334-5874      Fax:  (336) 334-3900

 

Lewis Z. Schlosser, Ph.D., Committee Member

Email: schlosle@shu.edu

Assistant Professor

Department of Professional Psychology and Family Therapy

Seton Hall University

400 S. Orange Avenue

S. Orange, NJ 07079

Office: (973)-275-2503            Fax: (973)-275-2188