Academy of Correctional Health Professionals
Your Professional community for Correctional Health Care

Mentor Information

Name
Mailing Address
City
State
Zip Code
Telephone
Mobile Phone
Email
Educational Degrees/Licensure
Certified Correctional Health Professional Certification
CCHP CCHP-A
Job Title/Current Position
Number of years in current position
If less than 3 years, last position
Profession (check all that apply)
Administrator Nurse practitioner Psychiatrist
Attorney Pharmacist Psychologist
Dentist Physician Social worker
Nurse Physician assistant Other
If Other please specify
Areas of Expertise (limit to 10 selections)
accreditation hospice care pharmacy management
budgeting infection control policies & procedures
chronic care clinics inmate co-pay procurement
conflict management juveniles quality improvement
contracting juveniles in adult facilities research
dental health legal issues staffing levels
disaster drills management staff recruitment/retention
discharge planning medical records substance abuse
end of life issues mental health utilization review
ethics opioid treatment programs women’s issues
HIPAA pain management Other
If Other please specify
Gender
Age
Facility Name/Employer
Work Setting
If Other please specify
If you work in a correctional facility, please provide the following information
Average Daily Population
Inmate population (check all that apply)
Male Female Adult Juvenile

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