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MEMBERSHIP
MEMBERS ONLY

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APPCN-TCN Mentorship Program
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Mentee Form

APPCN-TCN Mentorship Program

Mentee Form

Thank you for your interest in the APPCN-TCN Mentorship Program! Please complete this survey to be matched with a mentor for the 2024-2025 academic year.

This field is for validation purposes and should be left unchanged.

Personal Information

The following questions are intended to gather information about you, including your contact information, current position/training status, and interests.

Name(Required)

First Last

Preferred Email(Required)

Please indicate your training status or career level.(Required)

Post-Doctoral Fellow

Early Career Neuropsychologist

Other

Is your program an APPCN member?(Required)

Yes

No

Have you graduated from, or been accepted to, an APPCN-member postdoctoral program?(Required)

Yes

No

Thank you for your interest in the APPCN-TCN Mentorship Program. Currently, mentees must be current or recent graduates of an APPCN member postdoctoral program. Please contact appcn.tcn.mentorship@gmail.com with questions.

Please write in program details below:(Required)

Please provide your institution affiliation.(Required)

Please select your current/primary practice setting.(Required)

Academic Medical Center (AMC)

Veterans Affairs (VA) Medical Center

Private Hospital

Private Practice

Other

Primary population(s) of interest(Required)

Check all that apply.

Pediatric

Adult

Forensic

Other

Other(Required)

Research Experience

The following questions are aimed to gather your general research experience.

Approximately how many research publications do you have?(Required)

<3

3-5

5-10

>10

How many manuscripts have you published over the past three years?(Required)

None

1-2

3-5

>5

Please provide a few "key terms" to identify your research areas of interest/expertise (e.g., dementia, TBI, MCI, forensic, PVT).(Required)

Attestation

If you are a post-doctoral fellow, please provide the name and contact information for your Training Director and review the attestation statement below.

Training Director's Name(Required)

First Last

Email(Required)

Phone

Please acknowledge the following statement:(Required)

I have reviewed the program, time and effort requirements with my training director and they are in support of my participation of the APPCN-TCN mentorship program for 2024-2025.

I attest.

Please acknowledge the following statement:(Required)

I understand that I must be in attendance at the required APPCN-TCN webinar on October 15, 2025, or will need to watch the recording (available on the APPCN website) before I can be matched with a mentor.

I undersand.