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Internship Interest Form
Please complete this screening form to help us determine the best potential internship placement for you.
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* Indicates required question
Name
*
First and last name
Your answer
Email
*
Your answer
Phone number
*
Your answer
School
*
Your answer
Which placement(s) are you interested in?
*
Practicum
Internship 1
Internship 2
Required
Start Date per your graduate program
*
MM
/
DD
/
YYYY
When is the deadline for securing your placement?
*
MM
/
DD
/
YYYY
Number of weeks in the placement
*
Your answer
Number of direct contact hours (hours with clients directly) needed during this placement
*
Your answer
Number of supervision hours needed (specify individual v. group if necessary)
*
Your answer
License requirements for your supervisor
*
LMHC
LMFT
LCSW
Other:
Required
What other requirements does your program have for your placement?
Your answer
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