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CSWSH MENTOR APPLICATION
Name_______________________________ LCSW# ________
Address: _______________________________________________
Telephone: Home______________ Office_____________
Cell.________________ E-mail ______________________________
CSWSH Full Member : Yes___ No___ Years of practice as CSW __________
We plan to announce that the Mentoring Group will run for eight weeks. Are you able to make this type of commitment? If not, how much of a commitment would you be able to make?
___________________________________________________________________________
When you would be able to meet with the group? Please provide specific times:
Day_______________ Evening___________ Saturday___________ Sunday ___________
Would you want to run a support group as a sole leader or would you prefer to be a co-leader? Do you have someone in mind to co-lead with you? If so, please provide the name/s:
___________________________________________________________________________
Location to be used when meeting (either individually or as a leader of a support group) with social workers who are seeking mentorship:
___________________________________________________________________________
Projecting your time availability through the rest of 2005, when you would be available?
Please give specific dates. ______________________________________________________
With what kinds of service agencies are you familiar?
___________________________________________________________________________
Is there a geographical area that you know best?
___________________________________________________________________________
In what settings have you been employed?
___________________________________________________________________________
What are your practice specialties?
___________________________________________________________________________
List two CSWSH members who could serve as references:
___________________________________________________________________________
___________________________________________________________________________
CSWSH does not assume malpractice liability for mentors. It is expected that each Mentoring Group leader carries personal liability insurance coverage and will provide the following information:
My liability insurance is provided by:_______________________________________
Policy #______________________ Expiration date__________________________
You may use the back of this form to provide comments and suggestions. Please mail this application with your resume/vitae to : Nicholai M. Khiterer, Psy.D., LCSW, 300 Wai Nani Way #818, Honolulu, Hawaii 96815
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