Full legal name *

Preferred name

Email address *

Telephone number *

City *

State *

Preferred method of contact *

Phone

College or university *

Graduate counseling program *

Degree being pursued *

Concentration, if applicable

Expected graduation date *

Is your program CACREP accredited? *

Yes

Unsure

University faculty or internship coordinator name *

University faculty or internship coordinator email *

Requested semester *

Requested start date *

Requested end date *

Total placement hours required *

Direct client contact hours required *

Individual supervision hours required *

Group supervision hours required *

Additional university requirements

Resume or CV *

Click to upload

Unofficial Transcript *

Click to upload

University Internship Handbook or Clinical Placement Requirements

Click to upload

University Affiliation Agreement, if applicable

Click to upload

Other University Placement Documents

Click to upload

I certify that the information provided in this application is accurate to the best of my knowledge. *

I acknowledge

I understand that submission of an application does not guarantee placement with Coastal Virginia Mental Health Services. *

I acknowledge

I understand that acceptance is contingent upon CVMHS determining that it can reasonably meet my university's clinical placement requirements. *

I acknowledge

I understand that CVMHS clinical interns are expected to maintain a flexible schedule that includes daytime availability and participate in internship activities in blocks of at least four consecutive hours. *

I acknowledge

I understand that additional documentation, screening, university agreements, background checks, or onboarding requirements may be required before beginning my placement. *

I acknowledge

Electronic signature *

Clear

Date *

CVMHS clinical interns must maintain a flexible schedule that includes daytime availability. Internship activities must be scheduled in blocks of at least four consecutive hours.