Become a Mentor

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Step 1 of 3 – General Information

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Support your colleagues to become more confident and prepared in their clinical practices preventing and treating opioid use disorder and other substance use disorders. Become a mentor today.

Addiction and overdose continue to sweep across the United States, leaving communities and health professionals with a challenging task. Now more than ever, it is vital that our medical community unites to share evidence-based practices in the prevention and treatment of opioid use disorder (OUD). PCSS-MOUD provides a vast array of educational and training resources to support health professionals. While many prescribers are waivered to provide medications in treating OUD, far too many do not prescribe. In an effort to support clinicians to gain confidence and the necessary skills in treating their patients with OUD and chronic pain, PCSS-MOUD offers a Mentoring Program, available at no cost, to all providers. PCSS-MOUD Mentors are a network of health professionals, some addiction and pain experts and others with experience in prescribing medications for treatment of OUD. Mentoring can be provided by telephone, email or in person (if logistically possible).

If you are interested in applying to become a PCSS-MOUD mentor and support your colleagues, complete the application below. All applications are reviewed by PCSS-MOUD Lead Mentors. PCSS-MOUD staff will notify applicants following review.

Name*

First Name Last Name

Email*

Phone*

Degree*

Medical School

Fellowship

Name of Residency Program (or other post graduate program)

Current Clinical Position (Role/Title)*

Board certification in Addictions. Check all that apply.

American Board of Medical Specialties (ABMS)

American Board of Preventative Medicine (ABPM)

American Board of Psychiatry and Neurology (ABPN)

American Board of Addiction Medicine (ABAM)

National Commission on Certification of Physicians Assistants (NCCPA)

Addictions Nursing Certification Board (ANCB)

Addictions Nursing Certification Board (ANCB) – Accreditation Board for Specialty Nursing Certification (ABSNC)

Other certification

Current Academic Affiliations

Clinical and research interests*

City you practice in*

State you practice in*

What are your organization affiliations? (Choose all that apply)

AAAP – American Academy of Addiction Psychiatry

AOAAM – American Osteopathic Academy of Addiction Medicine

AMERSA – Association for Medical Education and Research in Substance Abuse

APA – American Psychiatric Association

ASAM – American Society of Addiction Medicine

AAPA – American Academy of Physician Assistants

APNA – American Psychiatric Nurses Association

Other organization affiliation

Other organization affiliations

What is your Profession?*

Physician (DO, MD)

Nursing (Certified Nurse Midwife, Certified Nurse Specialist, Certified Registered Nurse Anesthetist, Nurse Practitioner, RN, Other)

Physician Assistant

Psychologist

Pharmacist

Social Worker

Counselor

Dentist

Other

What are your specialties and sub-specialties? Check all that apply.*

Addiction Medicine

Emergency Medicine

Infectious Disease

Neurology

OB/GYN

Pain Management

Primary Care (Family Medicine, Internal Medicine, Pediatrics)

Psychiatry (Addiction Psychiatry, Adolescent Psychiatry • Adult Psychiatry • Child Psychiatry, Forensic Psychiatry, Geriatrics Psychiatry)

Other

Current Clinical Practice Setting*

Academic Medical Center

Community Health Center

Emergency Department / Urgent Care

Federally Qualified Health Center (FQHC)

General Inpatient medical service

General Outpatient

Mental Health Treatment centers (Inpatient, Outpatient, Partial inpatient, crisis response, Community-based counseling and other services, etc.)

Pain Management Clinic

Pharmacy

Private Practice

Substance Use Disorder Treatment center (Outpatient, Inpatient (Resident , Community-Based))

VA Hospital

Other

Years of experience in treating Substance Use Disorder / Medications for Opioid Use Disorder*

Years of experience prescribing Medications for Opioid Use Disorder*

Which medication(s) do you prescribe in the treating OUD/SUD?*

Buprenorphine

Extended-release naltrexone

Methadone

Naltrexone

Buprenorphine extended-release

Do you prefer to mentor regarding a particular medication?*

Yes

If yes, which medication(s) do you prefer?

Buprenorphine

Extended-release Naltrexone

Methadone

Naltrexone

Buprenorphine extended-release

Years teaching/training

Years of mentoring experience

Do you support long-term maintenance with medication for treating Opioid Use Disorder?*

Yes

If approved, what mode of communication would be best suitable for you to connect with your mentees? Check all that apply.*

Phone

In-person

Please submit your current curriculum vitae*

Max. file size: 50 MB.

Please provide two references familiar with your practice in these areas (name and contact info)*

Reference #1

Reference #2*

Reference #2

Upload a Professional Headshot. If approved, this photo will be added to your profile in the mentor directory.*

Max. file size: 50 MB.

Where did you hear about us?*

AAAP Annual Meeting and Trainings

Colleague

Conference

Email/Newsletter

Facebook

Family or Friend

Magazine/Newspaper

Opioid Response Network (ORN)

PCSS Partner Organization

PCSS Website

SAMHSA / NIDA / NIAAA – Federal Agency

Search Engine

Twitter

YouTube

Other

Representations and Warranties. AAAP may terminate the mentoring arrangement under this Agreement for any reason, including but not limited to, a violation of the representations and warranties contained in the section below. As a PCSS Mentor, I agree to provide AAAP with immediate notice of any violation of these representations and warranties. To confirm and agree to the following information, select “Yes”

1. I understand and agree that mentees seeking guidance from me as a PCSS-MOUD Mentor will be requesting education and training to aid them in providing evidence-based clinical practices.*

Yes

If no, please explain:*

2. I understand that my role is not to become involved in the treatment decisions with respect to any particular patient, but to provide the mentee with educational resources and information to consider for their clinical practices*

Yes

If no, please explain:*

3. I agree to exercise my professional judgment and reasonable diligence in recommending the mentee to educational resources that are evidence-based.*

Yes

If no, please explain:*

4. I agree that I will not violate the terms of any PCSS-MOUD agreement with, or any obligation to, another institution organization, employer or individual.*

Yes

If no, please explain:*

5. I agree that I am not presently suspended, proposed for suspension, declared ineligible, or voluntarily excluded from clinical practice by any federal, state or local department or agency.*

Yes

If no, please explain:*

6. I confirm that I possesses a valid medical license from all jurisdictions in which I practice and abide by all laws and regulations governing prescribers in these jurisdictions.*

Yes

If no, please explain:*

7. I confirm that I am not currently under investigation for any violation of the law by any government or regulatory authority.*

Yes

If no, please explain:*

8. I confirm that I have not been indicted, charged or convicted of any violation of the law.*

Yes

If no, please explain:*

Legal Right. If approved as a PCSS-MOUD Mentor, I agree to indemnify and hold harmless AAAP (PCSS-MOUD) from any and all damages, claims and expenses including attorney’s fees arising out of or resulting from any claim that this Agreement violates any such agreements.*

I agree

E-Signature*

Please type in Full name as your E-signature

Date*

mm/dd/yyyy

Security Check

Become a Mentor

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