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Step One

First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Home Phone Number
Cell Number*
E-mail Address*
Name of Graduate School*
Degree Program*
Status of Degree Program*
1. Completed
2. In Progress
Date of Degree Obtained or Projected Date*
Date of Degree Obtained or Projected Date
AMFT/APCC Intern Registration Number
(Type in N/A if not applicable)
Number of supervised clinical hours you will have completed by Aug. 2021*
Type in N/A if not applicable
How did you hear about this internship?*
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Briefly describe the following including relevant volunteer and life experiences:
Counseling/other experience with families*
Counseling/other experience with children and/or adolescents*
Counseling/other experience with clients from diverse cultures*
Counseling/other experience with low-income clients/individuals*
Experience or training in crisis intervention*
Other life experience or previous occupations you consider relevant*
Indicate languages, in addition to English, in which you could conduct a counseling session:
Will you have completed the following courses by August 2021?
Law and Ethics*
1. Yes
2. No
Child Abuse Reporting*
1. Yes
2. No
Family Therapy*
1. Yes
2. No
Child Therapy*
1. Yes
2. No
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Do you have a preference at this point among the program options?*
(Please review the options on the placement flyer in making your choices. You may check more than one.)
1. School Site/Clinic
1. Clinic
1. Police Department
Please submit the following with your application:
Upload Resume or CV
Upload most recent transcripts (unofficial)
Upload three (3) reference letters or reference contacts, including email addresses and phone numbers. At least two must be able to speak to your clinical skills or experience (i.e. graduate school professor or supervisor)
Upload Letters of Recommendation or Reference Contacts
Upload Letters of Recommendation or Reference Contacts
Upload Letters of Recommendation or Reference Contacts
I authorize Youth and Family Services (YFS) staff to contact the references provided to discuss my qualifications for the internship/practicum program at YFS. I certify that the above information is true, complete, and correct to the best of my knowledge. I understand that misstatements may subject me to disqualification or dismissal.
E- Signature
Date
Date
Required*
1. Please accept this electronic signature