QM Application - Students Mentored

Applicant Name	Date

List, in chronological order, three (3) students you have successfully mentored through certification starting with the most recent.

1. Mentee’s Last Name First Name

Year of Mentee’s Certification

Length of mentorship with this mentee

I served as the supervising nurse mentor in this mentorship Yes No

Was a supervising mentor included in this mentorship? Yes No

If yes, name of the supervising mentor:

I served as the nurse mentor in this mentorship and no other HTCP mentor was part of this mentoring relationship. Yes No

2. Mentee’s Last Name First Name

Year of Mentee’s Certification

Length of mentorship with this mentee

I served as the supervising nurse mentor in this mentorship Yes No

Was a supervising mentor included in this mentorship? Yes No

If yes, name of the supervising mentor:

I served as the nurse mentor in this mentorship and no other HTCP mentor was part of this mentoring relationship. Yes No

3. Mentee’s Last Name First Name

Year of Mentee’s Certification

Length of mentorship with this mentee

I served as the supervising nurse mentor in this mentorship Yes No

Was a supervising mentor included in this mentorship? Yes No

If yes, name of the supervising mentor:

I served as the nurse mentor in this mentorship and no other HTCP mentor was part of this mentoring relationship. Yes No

© Copyright 2010 Healing Touch Program HTP-942-B Rev 05.30.11

Margaret Nies

2011-05-31