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About
Goals and Objectives
Steering Committee
Newsletter
Success Stories
Latest News
Contact PCSS-MOUD
Education & Training
Search Training Directory
Clinical Tools
Curricula
Pain Core Curriculum
SUD 101 Core Curriculum Library
SUD for the Healthcare Team
8-Hour DEA Training
Live Virtual Learning
Upcoming Events
Clinical Roundtable Discussions
PCSS-MOUD Exchange
On-Demand
Webinars
Modules
Videos
Podcasts
Performance-in-Practice (PIP)
PCSS-MOUD Implementation
8-Hour DEA Training
8-Hour Education Options
Upcoming Live Trainings
Request to Host a Live MOUD Training
Mentoring
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Lead Mentors
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Become a Mentor
Home
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PCSS-MOUD Mentoring Program
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Become a Mentor
Become a Mentor
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3
– General Information
33%
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
Last
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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Years of experience in treating Substance Use Disorder / Medications for Opioid Use Disorder
*
None
1-3 years
3-5 years
5-10 years
Over 10 years
Years of experience prescribing Medications for Opioid Use Disorder
*
None
1-3 years
3-5 years
5-10 years
Over 10 years
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
No
If yes, which medication(s) do you prefer?
Buprenorphine
Extended-release Naltrexone
Methadone
Naltrexone
Buprenorphine extended-release
Years teaching/training
None
1-3 years
3-5 years
5-10 years
Over 10 years
Years of mentoring experience
None
1-3 years
3-5 years
5-10 years
Over 10 years
Do you support long-term maintenance with medication for treating Opioid Use Disorder?
*
Yes
No
If approved, what mode of communication would be best suitable for you to connect with your mentees? Check all that apply.
*
Phone
Email
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
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
No
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
No
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
No
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
No
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
No
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
No
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
No
If no, please explain:
*
8. I confirm that I have not been indicted, charged or convicted of any violation of the law.
*
Yes
No
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
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