Clinical Supervision & Training Interest Form

Interested in an internship, practicum, supervision opportunity, or other clinical training experience with Empowering Lives Initiative? Complete the form below so our team can learn more about your goals and determine whether a current opportunity may be a good fit.

Contact Information

First Name

Last Name

Phone *

Email *

City *

State *

Education

School/University *

Degree Program *

Expected Graduation Date

Current Year in Program

Is this opportunity required for your degree program?

Opportunity Requested

What type of opportunity are you seeking? *

Placement Information

Expected Start Date *

Expected End Date

Number of hours required

Days/times available

Virtual / In-person / Hybrid-Flexible?

Clinical Interests

Populations you are interested in working with

Areas of clinical interest

Previous behavioral health experience

School Requirements

Does your school require an affiliation agreement?

Does your school require a specific supervisor credential?

Describe any school-specific placement requirements

Application Materials

Upload Résumé *

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Cover Letter

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload School/Placement Documentation

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Transcript, if available

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Short Response

Why are you interested in training with ELI? *

What are your primary learning goals? *

What are you hoping to gain from this experience? *

Is there anything else we should know?

I understand that submitting this form does not guarantee an interview, supervision agreement, internship, practicum, or placement.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from The Empowering Lives Initiative at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.