Needs Assessment Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Yes, subscribe me to your newsletter.

How do you identify your gender?

Masculine Presenting

Non-binary

Genderqueer

Other

Please describe your current career stage (e.g., student, entry-level, mid-career, etc.):

What industry or field are you currently involved in or interested in pursuing?

What are your professional goals for the next 1-3 years?

What skills or areas of knowledge would you like to develop through this mentorship program?

Are there specific topics or issues you would like to discuss with your mentor? (e.g., career advancement, networking, confidence building)

What challenges or barriers have you faced in your career or academic journey? (Select all that apply)

What type of mentorship format do you prefer? (Select one)

One-on-one mentoring

Group mentoring

Workshops and networking events

A combination of the above

What is your preferred method of communication with your mentor? (Select all that apply)

How often would you like to meet with your mentor?

Weekly

Bi Weekly

Monthly

Other

Is there anything else you would like us to know about your needs or expectations for the mentorship program?

I consent to the use of my responses to help inform the development of the mentorship program.

I would like to receive updates about the mentorship program and related events.