Mentorship Program Request Form Full Name*Date of Birth/Age*Email Address*Phone Number*Current City, State/Province, Country*Current Profession/Role*Current Company/Organization*LinkedIn Profile URL (Optional)Highest Level of Education Attained* High SchoolAssociatesBachelor’s DegreeMaster’s DegreeDoctorate (Ph.D./M.D./J.D., etc.)OtherYears of Professional Experience in Your Field*Have you participated in a formal mentorship program before?*YesNoIf Yes: Briefly describe the nature and duration of that mentorship.What is your primary motivation for seeking mentorship at this time?*What specifically would you like to gain, learn, or otherwise experience during this mentorship program?*What are the biggest challenges you are currently facing in your career/professional life that you hope Dr. Patel can help you address?*What does success in this mentorship look like to you?*How much time per week, on average, are you prepared to dedicate to mentorship activities (meetings, homework, preparation)?*1-2 hours2-4 hours4+ hoursPlease select your desired Mentorship Program:*Hourly Mentorship – $350 per hour10-Hour Mentorship Block – $3000Custom Mentorship Curriculum – $5000-$15000Describe your “ideal curriculum for mentorship” with Dr. Patel.*When is your ideal start date for the mentorship?*How did you hear about Dr. Patel’s Mentorship Program?I understand that submitting this form does not guarantee acceptance into the program. I certify that the information provided is accurate and complete.*EmailSubmit Please enable JavaScript in your browser to submit the form
