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Education & Training
8-Hour DEA Training
Mentoring

About
Education & Training
8-Hour DEA Training
Mentoring

Home / PCSS-MOUD Mentoring Program / Mentor Request Form

Mentor Request Form

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If you would like a mentor, we ask that you complete the form below. Once received, we will identify a mentor who best suits your needs. If you need additional information, contact us (888) 572-7724.
Name*
First Last
Degree (MD/DO, NP, PA, PharmD, etc.)*
What type of mentoring are you looking for?*
- Brief Mentoring (ask a question or advice for resources and training)
- Intensive Mentoring (ongoing communication and support handling complex clinical situations)
What are your goals for having a mentor? Check all that apply.*
- Select All
- Guidance on treating pain
- Guidance on medication-based treatment of OUD
- Guidance on prevention and psychosocial interventions for OUD
- Guidance on administrative aspects of clinical practice
PCSS-MOUD is collaborating with another SAMHSA initiative, Opioid Response Network (ORN) on providing mentors for intensive mentoring in the areas of prevention, treatment and recovery. Therefore, we will be coordinating your request with the ORN initiative.

What are your goals for having a mentor? Check all that apply.
Prevention Options*
- Select All
- Adolescent/Young Adult Prevention
- Drug Take Back/Disposal
- Evidence-based Prevention Programs (e.g. Life Skills, Strengthening Families) & other prevention activities
- Implementation TA/Systems Change
- Media/Public Awareness Campaigns
- Naloxone training/distribution
- Prevention Coalition Building
- Safe opioid prescribing/prescription drug abuse related to local policies and regulations (e.g. PDMP)
- SBIRT: General, adolescent, Emergency Department
- School/Education Programs
Treatment Options*
- Select All
- Buprenorphine Induction in Emergency Department
- Buprenorphine Training
- Collaborative/Integrated Care Models
- Implementation TA/Systems change (e.g. assess organizational characteristics and apply appropriate implementation supports to build site capacity to integrate OUD services)
- MAT General, including clinical mentorship and implementation facilitation
- Pain Management
- Pharmacotherapy: Buprenorphine
- Pharmacotherapy: Methadone
- Pharmacotherapy: Naltrexone
- Psychosocial interventions (e.g. motivational interviewing, Cognitive Behavioral Therapy, clinical supervision)
- Telepsychiatry/Telehealth
- Treatment of co-occurring psychiatric disorders
- Youth-specific (Pharmacotherapy or Behavioral Treatment)
Recovery Options*
- Select All
- Experimentation TA/Systems Change
- Integration of Peers/Peer Supervision
- Medication-assisted Recovery
- Peer Support/Recovery Coach Models
- Peer Workforce Development
- Recovery Coalition/Community Building
- Recovery-oriented System of Care (ROSC)
- Recovery Housing
- Youth/Young Adult Recovery
Are you affiliated with your state's Opioid STR Project?*
- Yes
- No
How are you affiliated with your state's Opioid STR Project?*
- SSA or designee
- STR Project Director
- STR Project Staff
Are you involved in a Tribal Opioid Response (TOR) grant from SAMHSA?*
- Yes
- No
- Not Sure
Please use the area below to include additional information to describe your needs.*
How soon do you need to connect with a mentor?*
- As soon as a mentor is available
- In the next week
- In the next month
How long do you anticipate needing a mentor?*
- 1 Month
- 2-3 Months
- 3-6 Months
Please indicate the frequency at which you would like to connect with your mentor*
- Weekly
- Bi-Weekly
- Monthly
Is it important for your mentor to be geographically located near you?*
- Yes
- No
If you prefer a mentor with experience with a particular medication, which one?*
- Buprenorphine
- Methadone
- Naltrexone
- XR-Naltrexone
If you have a mentor you would like to work with, indicate below. We will attempt to provide this mentor to you pending their availability. To find a mentor, search our Mentor Directory.
Requested Mentor #1
Requested Mentor #1
Requested Mentor #2
Requested Mentor #2

Do you plan to prescribe medications in treating patients with OUD?*
- Yes
- No
Years of experience in providing treatment for those with substance use disorders.*
Years of experience prescribing medications in treating substance use disorders.*
What medications do you prescribe?*
- Buprenorphine
- Methadone
- Naltrexone
- XR-Naltrexone
- None of the Above
Number of patients you treat with medications for OUD*
- 0
- 1-25
- 26-50
- 51-75
- 76 or more
Number of clinical staff currently working in your clinical practice*
- 0
- 1-25
- 26-50
- 51-75
- 76 or more
Please submit your current curriculum vitae*
Max. file size: 50 MB.

Current Position (Role/Title) and Health Profession*
Post Residency/Post Graduate Training*
State you practice in*
City you practice in*
Email*
Phone*
What is your healthcare or medical specialty?*
- Addiction Medicine
- Addiction Psychiatry
- Emergency Medicine
- Family Medicine
- Infectious Disease
- Internal Medicine
- Neurology
- Obstetrics and Gynecology
- Pain Management
- Pediatrics
- Psychiatry (child, adolescent, or adult)
- Surgery
Type of practice (setting)*
- Academic Medical Center
- Addiction treatment inpatient program or clinic
- Addiction treatment outpatient program or clinic
- General inpatient medical service
- General outpatient medical clinic
- In Training
- Office-based
- VA Hospital
Where did you hear about us?*
- Colleague
- Conference
- Email/Newsletter
- Facebook
- Family or Friend
- Magazine/Newspaper
- Opioid Response Network (ORN) (website, conference, or training)
- PCSS-MOUD Exchange
- PCSS-MOUD Website
- PCSS-MOUD partner organization Annual Meeting and Trainings
- SAMHSA
- Search Engine
- Twitter
- Waiver Training for Medications for Treating Opioid Use Disorders
I understand and agree that all information that I receive through the PCSS-MOUD Mentoring Program is for educational purposes only and is not intended to replace or substitute for my professional clinical judgment with respect to my treatment of my patients. I understand that information provided or cited by a mentor is intended to broaden the decision-making resources available to me and that there can be no assurance that the resources to which a mentor directs me are comprehensive or provide a sufficient basis on which to base a clinical judgment with respect to the treatment of any specific patient. I further understand that I must exercise my professional clinical judgment with respect to the treatment of any specific patient and that I remain solely responsible when treating my patients or providing other professional services. I understand and agree that neither AAAP nor any mentor in the PCSS-MOUD Mentoring Program is responsible in any way for any treatment or services that I provide, regardless of whether I consulted the PCSS-MOUD Mentoring Program prior to making a treatment decision. I agree to indemnify and hold harmless AAAP and any PCSS-MOUD mentor for any claims – medical or otherwise – related to any professional services that I provide.*
- Yes, I understand

Rick Garcia, MD, Roger Chou, MD

Education and Training

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The content on this site is intended solely to inform and educate medical professionals. This site shall not be used for medical advice and is not a substitute for the advice or treatment of a qualified medical professional.

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T (855) 227-2776

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Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.