BA/BSW/ACSW/ AMFT Clinical Internship Questionnaire for TSP

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This form is to be completed by all Three Hart Connection Volunteers who have declared the desire to continuously volunteer with the organization.

Email *

Did you send your CV and Cover Letter to us via email? *

Yes

If not, please send both your CV and Cover Letter to nicole@threehartconnection.org before submission of this form. *

What is your T-Shirt size
*

XXL

Today's date:
*

YYYY

Please tell us your first and last name include preferred/nick names:
*

Provide your cell phone number below:
*

What is your home address?
*

Emergency Contact Info (Name, relation to you, & phone number)
*

Please indicate the following: *

Current MSW Student First Year

Current MSW Student Second Year

Current MSW Student Third Year

Current MFT Student First Year

Current MFT Student Second Year

Current MFT Student Third Year

ACSW (with current license number)

AMFT (with current license number)

Post Grad MSW (without a current license number)

Post Grad MFT ( without a current license number)

BA Student First Year

BA Student Second Year

BA Student Third Year

BA Student Senior

Post Grad BA

BSW Student First Year

BSW Student Second Year

BSW Student Third Year

BSW Student Senior

Post Grad BSW

Please provide your ACSW/AMFT license number: *

As part of our Volunteer /Internship position we require completion of a Non-Disclosure Agreement (NDA) and register/complete background check. Are you in agreement?
*

Yes

What is your commitment level? *

Are you looking to complete 10-80 hours for a community service project? If so, please share with us why you picked our agency? *

If you are interested in accruing clinical hours towards your license ( LMFT or LCSW), please share with us how many hours you have already accumulated. Please also share, why you picked our agency. *

How many years of experience do you have in the mental health clinical field?
*

Do you have prior experience working with the domestic violence population.
*

Yes

If so, how many years of experience do you have? *

If not, please list the populations you have worked with, what capacity and how many years of service? *

Please list all other languages, you speak fluently other than English. *

What specialized modalities are your scope of practice as a mental health therapist?
*

Tell us about your prior experience in volunteering? Please be certain to include specific agencies, time frames and dates.
*

Please share your personal and professional goals while volunteering with Three Hart Connection.
*

Please share how our mission statement at Three Hart Connection align with your core beliefs and values.
*

Do you have any criminal history? If yes, please explain.
*

What is your Myers-Briggs? 16personalities.com

What is your Love Language? 5lovelanguages.com

What do you do when you feel pressure, anxiety, or stress?

What areas are you naturally gifted ?

What talents you are skilled in?
*

Are you certified or trained as an Instructor in the following. *

40 Hours DV Certification

DV Trainer/Instructor

Parenting Class Certification

Parenting Class Trainer/Instructor

Anger Management Certification

Anger Management Trainer/Instructor

CSEC Certification

CSEC Trainer/Instructor

EMDR Certification

EMDR Trainer

EMDR Consultant

Art Therapy Certification

Trauma Informed Therapy Certification

Trauma Informed Therapy Trainer

Other:

Required

If you checked yes to any of the above mentioned questions, please indicate what agency(ies) and what year(s) were you certified?
*

If you have experience as a Trainer/Instructor, please indicate through what agency (ies) you received your training. Please be certain to include specific time frames and dates.
*

How many years of experience as a Trainer/Instructor do you have? Please be certain to include specific time frames and dates.
*

Are you an active Trainer/Instructor now? If so, what organizations/colleges, non-profit or government agencies are you partnered with currently? Please be certain to include specific time frames and dates.
*

If your status is inactive, please share what organizations/colleges, non-profit or government agencies you have partnered with in the past. Please be certain to include specific time frames and dates.
*

Please list any other areas that you are currently certified in or trained to practice or instruct. Please also include the year you were certified, how many years you have actively practiced or instructed, and where you received your certification/training in this specific skill. Please make sure to include specific organizations/colleges, non-profits, government agencies, time frames, and dates. *

Please indicate your availability to provide therapy services to clients.
*

Days

Afternoons

Evenings

Weekdays only

Weekends

In-person (at our on-site location)

On-line TeleHealth

Other:

Required

Please indicate the days you are available.
*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Required

Please list specific times you are available below.
*

Time

What have been some of the most significant events that have shaped your life? (Describe your top 3)
*

Please provide us 3 personal references and include contact information below: *

Please provide us 3 professional references and include contact information below: *

Please share anything else would like us to know about you:
*

A copy of your responses will be emailed to the address you provided.

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