I reside in the following ABCP region (please check one): Northeast: Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York, Pennsylvania, New Jersey, and Eastern Canadian Provinces (Newfoundland and Labrador, Nova Scotia, Prince Edward Island, New Brunswick, and Quebec) Mideast: Delaware, Maryland, West Virginia, Virginia, District of Columbia, North Carolina Southeast: Tennessee, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana Midwestern: Ohio, Kentucky, Indiana, Michigan, Wisconsin, Illinois, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas, and Middle Canadian Provinces (Ontario, Manitoba, Saskatchewan, and Alberta) Intermountain: Alaska, Arkansas, Texas, Oklahoma, Montana, Wyoming, Colorado, New Mexico, Idaho, Utah Western: Washington, Oregon, California, Nevada, Arizona, Hawaii, and Western Canadian Province (British Columbia) I wish to volunteer as a mentor for a psychologist who has entered into Candidacy to become Board Certified in Clinical Psychology. I attest to the following (please initial each item): Initial I am a Board Certified Psychologist in Clinical Psychology and my annual ______ attestation with ABPP is current. ______ I have served on at least 3 examination committees in the past. I have participated either as a Chair or Member on ________ examination ______ committee(s) during the past 12 months. I confirm that I will thoroughly review the Examination Manual to be employed by ______ this Candidate, prior to engaging with the Candidate. I have re-read the Mentor and Mentee Handbook (in this Form has been ______ embedded) and agree to its contents. _____________________________________ ____________________________________ Signature Date: Send this completed form to: Ira Grossman, Ph.D., ABPP: ABCP Mentorship Coordinator E-mail: Fax: (619) 795-9993 Appendix C: Mentor Request Form REQUEST FOR MENTOR Complete this form and forward it to the Mentoring Coordinator.
I reside in the following ABCP region (please check one): Northeast: Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York, Pennsylvania, New Jersey, and Eastern Canadian Provinces (Newfoundland and Labrador, Nova Scotia, Prince Edward Island, New Brunswick, and Quebec) Mideast: Delaware, Maryland, West Virginia, Virginia, District of Columbia, North Carolina Southeast: Tennessee, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana Midwestern: Ohio, Kentucky, Indiana, Michigan, Wisconsin, Illinois, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas, and Middle Canadian Provinces (Ontario, Manitoba, Saskatchewan, and Alberta) Intermountain: Alaska, Arkansas, Texas, Oklahoma, Montana, Wyoming, Colorado, New Mexico, Idaho, Utah Western: Washington, Oregon, California, Nevada, Arizona, Hawaii, and Western Canadian Province (British Columbia) I wish to volunteer as a mentor for a psychologist who has entered into Candidacy to become Board Certified in Clinical Psychology. I attest to the following (please initial each item): Initial ______ I am a Board Certified Psychologist in Clinical Psychology and my annual attestation with ABPP is current. ______ I have served on at least 3 examination committees in the past. ______ I have participated either as a Chair or Member on ________ examination committee(s) during the past 12 months. ______ I confirm that I will thoroughly review the Examination Manual to be employed by this Candidate, prior to engaging with the Candidate. ______ I have re-read the Mentor and Mentee Handbook (in this Form has been embedded) and agree to its contents. _____________________________________ ____________________________________ Signature Date: Send this completed form to: Ira Grossman, Ph.D., ABPP: ABCP Mentorship Coordinator E-mail: Fax: (619) 795-9993 Appendix C: Mentor Request Form REQUEST FOR MENTOR Complete this form and forward it to the Mentoring Coordinator.