Personal Information

First Name

Last Name

Phone *

Email *

Street Address

City

State

Country

Postal code

Academic Information

Are you legally eligible to work in the U.S.?

Yes

No

University/College Name

Degree Program

Year in Program

Expected Graduation Date

Internship Coordinator Name

Internship Coordinator Contact

Does your program require a formal affiliation agreement?

Yes

No

Unsure

Internship Logistics

Desired Internship Start Date

Total Hours Needed to Complete Internship

Preferred Weekly Schedule (Days/Times Available)

Are you seeking clinical or non-clinical placement?

Experience & Interests

Have you had previous internship or practicum experience?

Yes

No

If Yes, Briefly Describe

Our program is best suited to students in the 2nd or 3rd year of graduate studies who have advanced academic preparation. Please select the courses you have completed to date:

What populations are you most interested in working with?

Children

Adults

Seniors

Do you speak a second language?

Please upload the following:

CV/Resume

Cover Letter

Writing Sample

Please upload a redacted writing sample such as a recent research paper, communication to supervisor or other entity, client note, etc.

Academic/Professional Reference

Name
Relationship
Email
Phone

Please note, we are not accepting undergraduate or first year graduate students at this present time.