Appendix C

Mentor Consent Form

The role of the Mentor is to serve as an expert in the field chosen by the student. By signing this form, the
mentor agrees to: allocate time (a minimum of ten hours) to work with the student; provide insight into the
training, expectations, and demands of the field; ensure that the student is actively involved during shadowing
and not simply observing. If desired, the mentor may provide suggestions, advice, and support regarding the
development of a tangible product that connects to the real-world requirements of the career.

Student Name __________________________________________________________________

Project Topic ___________________________________________________________________

Mindfulness as a Strategy to Treat Dissociation

Mentor Name ___________________________________________________________________

Dr. Nancy Zucker

Duke University
Place of Employment _____________________________________________________________

P.O. 3842, Duke University, Durham, NC 27710

Work Address ____________________________________________________________________

Preferred Email __________________________________________________________________

nancy.zucker@duke.edu

Preferred Phone _________________________

919-308-9140

Occupation / Title / Expertise Related to Topic ___________________________________________

I am a clinical researcher and clinical psychologist who

works with individuals who feel disconnected from their bodies and this disconnection contributes to poor mental health.
________________________________________________________________________________
Years of experience in topic area ____________________
25

For the protection of myself and the student, I agree that we will not meet alone. I agree to uphold the
roles/duties of the project mentor to the best of my ability. I also confirm that I am not related to the student.

Mentor Signature ________________________________________________ Date ______________

9/11/17

Parent Signature _________________________________________________ Date ______________

Student Signature ________________________________________________ Date ______________