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Surviving STEM Interest Form
Home
Services
Get Involved
Testimonials
Blog
Surviving STEM Interest Form
Surviving STEM Interest Form
Thank you for your interest in joining
Surviving STEM
! Please complete the form below to let us know how you'd like to get involved.
1. Personal Information
Full Name:
(Required)
Email:
(Required)
Phone:
Address:
(Required)
City
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
2. Tell Us About Yourself
Current Role:
(Required)
PhD Student
Postdoc
STEM Professional
Mental Health Professional
Other
Experience in STEM:
(Required)
Yes
No
Educational Background (Degree and Field):
(Required)
Counseling Certification (if applicable):
Yes (please specify)
No, but I’m interested in obtaining one.
Please Specify Counseling Certification:
3. How Would You Like to Get Involved?
Join as a Counselor
Join as a Counselor
Do you have experience in STEM?
(Required)
Yes
No
Do you hold a counseling certificate?
(Required)
Yes
No, but I’m interested in obtaining one.
Participate in the Pilot Program
Participate in the Pilot Program
Are you a PhD student or postdoc?
(Required)
Yes
No
Area(s) of focus you’re interested in:
(Required)
Mental Health Support
Career Coaching
Academic Writing & Publishing Support
Peer Support
Join the Advisory Board
Join the Advisory Board
Please provide a brief summary of your experience in STEM or mental health:
(Required)
Volunteer
Volunteer
Area(s) you’d like to support:
(Required)
Content Development
Community Engagement
Outreach and Advocacy
Partner with Us
Partner with Us
Please specify your organization and proposed collaboration:
(Required)
4. Share Your Ideas or Questions
If there’s anything else you’d like to share or ask, let us know!
5. Next Steps
After submitting your interest form, we’ll be in touch with next steps and opportunities to get involved.
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