REQUEST FOR SUPERVISED EXPERIENCE
FORMAL SUPERVISED TRAINING REQUEST FORM
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Email *
First Name *
Last Name *
Email Address: *
Daytime Phone *
Secondary Phone
Are you age 18 or above? *
Date of Birth *
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Do you have any internship restrictions? *
If you have internship restrictions, please describe.
What is your current student status? *
If you are still in school, please provide the name of your educational institution? *
If you are still in school, please provide the contact information (e.g., name, email, phone) of your Training Director / Field Liaison. *
Are you a registered PCC, ACSW, AMFT, or other clinical professional, needing formal internship hours to obtain licensure? *
Are you a registered post-graduate doctoral psychology fellow in need of formal supervised hours to obtain licensure? *
For what discipline do you need supervised training experience for? (e.g., psychology, social work, counseling, mental health nurse practitioner, para professional, etc.) *
How many supervised experience hours do you need, and in what timeframe? *
Approximately when would you need your supervised training to begin? *
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If given an internship placement at Youth Enterprise, Inc., briefly describe the impact you hope to make in the community with your service? *
Briefly describe what you hope to learn/ gain from a formal internship with Youth Enterprise, Inc.? *
Please indicate other agencies/organizations/institutions at which you have completed internship or training hours: *
Please indicate your strengths and current skill sets. *
Please provide any additional information regarding your request to partner in service with Youth Enterprise, Inc.:
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