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  • FPSC Provincial Mentorship Program

    Application Form

  • Connecting Physicians, Inspiring Growth

    The FPSC Provincial Mentorship Program connects family physicians with mentorship at the individual, local, and provincial levels. Building on existing initiatives, this program expands opportunities for professional growth and collaboration throughout the province.
  • Format: (000) 000-0000.
  • I consent to my contact information being shared with my mentor/mentee match:*
  • Select which role you are applying for within the FPSC Provincial Mentorship Program.*

  • FPSC Provincial Mentorship Program Application Form

  • Please select the FPSC Provincial Mentorship Program stream(s) in which you would like to be a mentor. Please only select streams in which you have a minimum of 5 years clinical experience and feel comfortable mentoring in:
  • Pregnancy and Newborn Care
  • Please confirm if you have active hospital privileges?

  • Please Note: Active hospital privileges are required for participation in the inpatient care mentorship stream and facility-based Pregnancy and Newborn Care.

  • Do you currently or have you ever simultaneously had a longitudinal community practice and worked in this facility-based care stream?
  • How many mentees are you interested in supporting within a one-year timeframe? (Note: Mentors are consulted before all matches are made to ensure capacity)
  • How many mentees are you comfortable supporting at one time?
  • Are you willing to mentor physicians from outside of your Division of Family Practice?
  • When would you like to begin participating as a mentor?
  •  - -

  • To support our evaluation of the FPSC Provincial Mentorship Programs' effectiveness, please rate your agreement with the following statements. You will be asked these questions again at the end of your participation in the program.

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  • For additional information please refer to the Mentor Program Package.

  • FPSC Provincial Mentorship Program Application Form

  • Are you a Family Physician or Nurse Practitioner?
  • Please select the FPSC Provincial Mentorship Program(s) in which you would like to be a mentee:
  • Please specify your desired support in Pregnancy and Newborn Care:
  • Do you have hospital privileges?

  • Please Note: Active hospital privileges are required for participation in the inpatient care mentorship stream and facility-based Pregnancy and Newborn Care.

  • Do you currently or do you plan to work simultaneously in a longitudinal community practice and this facility-based care stream?

  • Identify 1-3 goals that you would like to accomplish during your participation in the mentorship program. (Consider what is relevant to your area of practice and long-term professional development):

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  • Would you be open to being paired with a mentor who is outside of your Division of Family Practice?
  • When would you like to begin the mentorship program?
  • Date:
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  • To support our evaluation of the FPSC Provincial Mentorship Programs' effectiveness, please rate your agreement with the following statements. You will be asked these questions again at the end of your participation in the program.

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  • More Mentorship Opportunities - Optional

    There are mentorship and coaching opportunities available from other organizations, including for rural physicians, clinic support and quality improvement. 

  • For additional information, please refer to the Mentee Program Package.

  • Agreements

    Please review all of the following documents and confirm you have read them by clicking the box next to each item:

  • Thank you for completing the application for the FPSC Provincial Mentorship Program.  One of our team members will reach out to you shortly with next steps.  

    Please feel free to email us with any questions about the program.

    FPSCmentoring@doctorsofbc.ca

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