BCAMN Mentee Application Form

Thank you for your interest in applying as a mentee to the BC Adaptive Mentorship Network (BCAMN). This application is intended for community-based primary care providers and allied health care professionals governed by the Health Professions Act who would like to join BCAMN as a Mentee.

Please fill out this brief questionnaire so we can learn more about you and learn which one of the small groups you would like to join.

First Name

Last Name

Email address

Phone number

Profession

How did you hear about the BCAMN?

What is the primary community where you practice?

(e.g. Victoria, Chetwynd, Sto:lo Nation)

Which of these settings best describes the structure of your main practice?

Please provide a very brief summary of why you would like to join BCAMN as a mentee.

(100 words or fewer)

Selecting the Small Group You Will Join

NOTE: YOU MUST COMPLETE THIS SECTION OR YOUR APPLICATION WILL NOT BE CONSIDERED

You will be assigned to your 1st choice of the small groups if a space is available in that group. If that group is at capacity, we will assign you to your 2nd choice. If that group is at capacity, we will assign you to your 3rd choice. Here are the Mentors assigned to each of the groups (Mentors photos and brief bios are on https://painbc.ca/bcamn):

GROUP 1: Valerie Hruschak, PhD, MSW, Richard McIlmoyle, BSc, DC, GCPain; Heather Fulton, B.Sc. (Hons), Ph.D., R. Psych., Cameron Ross, BSc, MD, CCFP, FCFP

GROUP 2: Sandra Hodge, BScN, MSN, NP(F), Susan Reid Schellinck, BSc (OT), BSc (Biol), Launette Rieb, MD, MSc, CCFP(AM), FCFP, CCSAM, DABAM, FASAM, Neil Pearson, M.Sc.(RHBS), B.Sc.PT, B.A.-B.P.H.E., C-IAYT, ERTY500

GROUP 3: Melanie McDonald, MSW, Judy Dercksen, MBBCH, MpraxMed, CCFP, FCFP, Kat Dikeakos, MSc, OT, Colin Phillips, BSc, MD, FRCPC

GROUP 4: Tori Etheridge, Dip. Sports Sci., B. Kin., M.P.T., Garry Palak, MB, BcH, BAO, FRCPC, Natasha Edney, Dip. Psych., MTC., Barbara Eddy, MN, NP(F)

Group 1

Group 2

Group 3

Group 4

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