NMAFP Pilot Mentorship ProgramPlease enable JavaScript in your browser to complete this form.Are you volunteering to be a mentor or looking for a mentor?I am volunteering to be a mentorI am looking for a mentorName *FirstLastEmail *EmailConfirm EmailPhone *County *— Select Choice —BernalilloCatronChavesCibolaColfaxCurryDe BacaDoña AnaEddyGrantGuadalupeHardingHidalgoLeaLincolnLos AlamosLunaMcKinleyMoraOteroQuayRio ArribaRooseveltSan JuanSan MiguelSandovalSanta FeSierraSocorroTaosTorranceUnionValencia areas than are Are you willing to have more than one mentee at a time? *YesNoWhat is the maximum number of mentees you are willing to have at one time? *What is your mentoring communication preference? *EmailIn-personOver the phoneVirtual meetingsNo preferenceWhat stage are you in your career? *— Select Choice —Resident/Fellow1-3 years post-training3-5 years post-training5-10 years post-training10+ years post-trainingRetiredRecent career shiftNot specifiedWhat are your areas of expertise? *Behavior change/patient activationClinical careCommunity outreachConducting researchDeveloping/integrating curriculumGeriatricsHealth equityIntervention development (healthcare settings)Lifestyle medicine healthcare administration/leadershipLifestyle medicine in the workplaceMen’s healthNutritionPayment and reimbursementPediatric/adolescentPhysical activityPlanetary healthyPositive social connectionPractice managementPresenting and speakingProgram development (community)SleepSpirituality, meaning, and/or purposeSubstance abuseWomen’s healthWriting/publishingWhat is your lifestyle medicine work setting/s? *Academic institutionAdministrationCommunity-based setting/program/free clinicConsultantDigital healthFQHC/CHCHealth systemMedical groupIf other:Which medical school do you attend? *— Select Choice —UNMBCOMWhich year of school are you? *— Select Choice —MS-IMS-IIMS-IIIMS-IVWhich year of school are you? *— Select Choice —OMS-IOMS-IIOMS-IIIOMS-IVWhat are your areas of interest? *Behavior change/patient activationClinical careCommunity outreachConducting researchDeveloping/integrating curriculumGeriatricsHealth equityIntervention development (healthcare settings)Lifestyle medicine healthcare administration/leadershipLifestyle medicine in the workplaceMen’s healthNutritionPayment and reimbursementPediatric/adolescentPhysical activityPlanetary healthyPositive social connectionPractice managementPresenting and speakingProgram development (community)SleepSpirituality, meaning, and/or purposeSubstance abuseWomen’s healthWriting/publishingAdditional comments (Work setting, areas of interest, availability, etc.)Submit
