Mentee Application Survey

Mentee Application Survey

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. Your responses will help us populate vacancies in the small groups of Mentees facilitated by a pair of Mentors, based on geographic distribution, professional diversity, and mentoring needs.

There is high demand for spaces as a BCAMN Mentee, and your application does not guarantee that you will be accepted as a Mentee.

First Name*

Last Name*

Email address*

Phone number*

Profession*

Select

How did you hear about the BCAMN?*

Select or enter value

Other

Please detail how you heard about the BCAMN mentee intake

Focused practice or other profession

If you chose "other" as your profession or indicated you are a family physician with a focused area of practice, please provide details here.

Under-represented communities

Pain BC encourages applications from people who self-identify as members of under-represented and systemically excluded communities, including Indigenous peoples, people of colour, and LGBTQ2S applicants. If you identify yourself as an applicant from an under-represented community and want to share this information with us, please provide details below. (optional)

How many years have you been in practice?*

What type of geographic community do you work in?*

Select

Other Community (write-in):

If you selected "other" in the question above, please provide details.

What is the primary community where you practice?*

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

Which of the following settings do you practice in?*

Select or enter value

Other Practice Setting

In which of BC's Health Authorities is your main practice located?*

Select

Other Health Authority

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

Select

What percentage of your total practice time involves patients experiencing pain? _____ % per week*

Please give an approximate percentage based on an average week.

What percentage of your total practice time involves patients who use substances? _____ % per week*

Please give an approximate percentage based on an average week.

What percentage of your total practice time involves patients with mental health conditions? _____ % per week*

Please give an approximate percentage based on an average week.

What proportion of your patients are experience social marginalization and/or socio-economic barriers to care? _____ %*

Examples include Indigenous peoples, people of colour, LGBTQ2S patients, and patients living in poverty.

Rank these topics in order of your greatest to least areas of need for mentorship and practice support/enhancement.*

Rank from 1 (greatest need) to 3 (lowest need).

Pain*

Select

Mental health*

Select

Substance use*

Select

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

(100 words or fewer)

Availability*

Please check all dates/times that you are available to meet.

Send me a copy of my responses

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