Intern Application Step I

Basic Info
* First Name
* Last Name
* Telephone
* Address
* City
* Zip
* Email
Language(s) other than English (including American Sign Language) in which you are FLUENT enough to conduct therapy?
Professional Conduct
* Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor, educational or training institution, health care institution, professional association, or licensing / certification board?
* Are there any complaints currently pending against you before any of the above bodies?
* Has there ever been a decision in a civil suit rendered against you relative to your professional work, or is any such action pending?
* Have you ever been put on probation, suspended, terminated, or asked to resign by a graduate or internship training program, practicum site, or employer?
* Have you ever been convicted of an offense against the law other than a minor traffic violation?
* Have you ever been convicted of a felony?
* Current College/University Name
* Program Name
Accreditation Status of Program
* Degree Seeking:
If you are seeking any Specialization or Certification, please list it here?
* Seeking?
* Anticipated Graduation Date
* Hours Required by Program for Internship (please distinguish total from direct hours required and any other specific hour requirements e.g. relational, somatic, etc.):
References -Please provide the names and contact information for two Professional References (at least one that can speak to your clinical skills):
* Reference #1 Name
* Reference #1 Relationship to Applicant
* Reference #1 E-mail
* Reference #1 Phone
Reference #1 Address
* Reference #2 Name
* Reference #2 Relationship to Applicant
* Reference #2 E-mail
* Reference #2 Phone
Reference #2 Address
* Are you available for a start date (to begin observations) the week of August 24, 2015?
* Are you available for Training Friday/Saturday, August 28 & 29, 2015?
* If selected as an intern with Judi’s House, are you willing to make a 12 month commitment?
How many months are required by your University?
* Can you be available every Thursday from 11am-4pm during the time of your internship?
Electronic Signature
I certify that all of the information submitted by me in this application is true to the best of my knowledge and belief.
I understand that any significant misstatement in, or omission from, this application may be cause for denial of selection as an intern or dismissal from an intern position.
I authorize the internship site to consult with persons and institutions with which I have been associated who may have information bearing on my professional competence, character, and ethical qualifications now or in the future.
I release from liability all internship staff for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications.
I also release from liability all individuals and organizations who provide information to the internship site in good faith and without malice concerning my professional competence, ethics, character, and other qualifications now or in the future.
I authorize the internship site and my university program to release evaluative information about me to each other, now or in the future.
I further understand that it is my responsibility to inform the internship sites to which I have applied if a change in my status with my academic program, (e.g., being placed on probation, being dismissed, etc.) occurs subsequent to the submission of my
If I am accepted and become an intern, I expressly agree to comply fully with all applicable state, provincial and federal laws, all of the Rules and Code of Conduct of the State, and the rules of the institution in which I am an intern.
This authorization, which may be revoked at any time, supersedes any prior authorization involving the same subject matter.
* Signature: Please type full name if you are in agreement with all statements above.
Type the characters you see in the box