Mentorship Form

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Mentorship Form

- Step 1 of 6

The Confident Clinician Cooperative serves to assist future and practicing clinicians in effective, evidence-based voice treatment through mentoring opportunities. This form is intended to provide the CCC feedback to customize your mentoring experience.

Email *

Question

Demographics *

Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell phone number

In what setting(s) do you work? Select all that apply. *

Schools
Acute Care Hospital - Adults
Acute Care - Pediatrics
NICU
Outpatient Hospital - Adults
Outpatient Hospital - Pediatrics
Inpatient Rehabilitation
Long-Term Acute Care
VA hospital, outpatient or nursing home
Nursing home
Private practice - Adults
Private practice - Pediatrics
University clinic
Teletherapy - Adults
Teletherapy - Pediatrics

In what setting(s) do you DESIRE to work? Select all that apply.

Schools
Acute Care Hospital - Adults
Acute Care - Pediatrics
NICU
Outpatient Hospital - Adults
Outpatient Hospital - Pediatrics
Inpatient Rehabilitation
Long-Term Acute Care
VA hospital, outpatient or nursing home
Nursing home
Private practice - Adults
Private practice - Pediatrics
University clinic
Teletherapy - Adults
Teletherapy - Pediatrics

How long have you been practicing? *

0-5 years
6-10 years
11-15 years
15-20 years
20+ years

Discuss how much training you have had related to voice assessment and treatment?

What voice CEUs have you taken?

What are your goals in working with patients with voice and upper airway difficulties?

Mentorship

Would you prefer 1:1 mentoring? *

Yes
No

If you prefer cohorts, how many mentees do you need in your cohort? *

two
three
four

If you prefer cohorts, would you be interested in additional 1:1 mentorship sessions? *

Yes
No

Are you interested in one of us coaching YOU virtually while you provide services to your patient? *

Yes
No

Assessment

Do you require assistance with medical terminology related to anatomy/physiology of voice production?

Yes
No
Maybe

Do you require assistance with obtaining a past medical history from a patient?

Yes
No
Maybe

Do you require assistance with interpreting patient medication lists?

Yes
No
Maybe

Do you require assistance with Patient Reported Outcome Measures (PROM)?

Yes
No
Maybe

Do you require assistance with behavioral assessment of voice?

Yes
No
Maybe

Do you require assistance with perceptual assessment of voice?

Yes
No
Maybe

Do you require assistance with obtaining acoustic and aerodynamic measures?

Yes
No
Maybe

Do you require assistance using equipment/software for acoustic assessment?

Yes
No
Maybe

Do you require assistance using equipment/software for aerodynamic assessment?

Yes
No
Maybe

Do you require assistance with interpreting acoustic and aerodynamic data?

Yes
No
Maybe

Do you need assistance describing laryngeal pathologies?

Yes
No
Maybe

Do you require assistance with interpreting stroboscopic patterns/parameters of vocal fold vibration?

Yes
No
Maybe

Do you require assistance determining patient candidacy for voice therapy?

Yes
No
Maybe

Do you require assistance interpreting evaluation results?

Yes
No
Maybe

Do you require assistance with providing patient education regarding evaluation results and plan of care?

Yes
No
Maybe

Do you require assistance determining when a patient requires referral to another clinician (i.e. ENT, GI, mental health counseling, neurology, pulmonology, etc.)?

Yes
No
Maybe

Treatment

Do you feel comfortable implementing a treatment plan based on stroboscopy results?

Yes
No
Maybe

Do you feel comfortable implementing a treatment plan of care and writing goals?

Yes
No
Maybe

Which voice disorders/pathologies do you feel you need assistance assessing and treating? *

Muscle tension dysphonia
Vocal fold nodules, polyps, and cysts (phonotraumatic lesions)
Vocal fold hemorrhage
Vocal fold paresis/paralysis
Sulcus vocalis
Laryngeal papilloma
Functional aphonia
Neurologic voice disorder
Spasmodic dysphonia
Presbyphonia
Paradoxical vocal fold motion disorder
Chronic cough
Gender affirming voice and communication
Dysphonia related to cancer or effects of cancer treatment
Performing voice issues
Pediatric dysphonia

Which treatment approaches or techniques do you feel you need assistance? *

Resonant voice therapy
Semi-occluded vocal tract exercises (SOVT)
Flow phonation
Vocal Function Exercises
Straw phonation
Accent Method
Breathing capacity and coordination
Cup bubbles
Upper body stretching
Jaw and tongue relaxation
Relaxation techniques
Yawn-Sigh
Myofascial release
LSVT LOUD
SPEAK OUT!
PhoRTE
Conversational Training Therapy (CTT)
Vocal health and wellness / vocal fold injury prevention
Respiratory retraining
Cough suppression therapy

Do you require assistance selecting treatment approaches to use with patients? *

Yes
No
Maybe

Do you require assistance initiating a patient home program? *

Yes
No
Maybe

Do you require assistance with determining treatment duration? *

Yes
No
Maybe

Tell us about how we can help you! Any other comments too. *

Terms and Conditions

With purchase of mentorship services, I understand that these will be used in a timely manner. Emerald and Topaz Star sessions (individual or group a la carte for 60 minutes) are allotted 30 days to schedule and complete the session. Sapphire Star (individual or group bundled 5 hour-long sessions) purchases are allotted 180 days to schedule and complete the sessions. Diamond Star Clinician monthly consult package must be completed within a year. Please refer to www.confidentclinician.com for further details of gem-stone packages.

Acceptance Declaration *