Application For:
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Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Pronouns
*
They/Them
He/Him
She/Her
Are you fluent in any languages other than English? If yes, explain.
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Yes
No
Monday
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AM (8a-2P)
PM (2p-7p)
Both
Not Available
Tuesday
*
AM (8a-2P)
PM (2p-7p)
Both
Not Available
Wednesday
*
AM (8a-2P)
PM (2p-7p)
Both
Not Available
Thursday
*
AM (8a-2P)
PM (2p-7p)
Both
Not Available
Friday
*
AM (8a-2P)
PM (2p-7p)
Both
Not Available
Please list any relevant certifications: [e.g., CPR/First Aid, Crisis Intervention, etc.}
Please provide any previous clinical experience, practicum placements, or relevant volunteer work.
if you have previous clinical experience, please provide the location, dates worked, supervisor and a brief description of responsibilities.
Theoretical Orientation
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Briefly describe your current theoretical orientation and approach to counseling
Individual Counseling
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1
2
3
4
5
Group Counseling
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1
2
3
4
5
Crisis Intervention
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1
2
3
4
5
Assessment and Diagnosis
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1
2
3
4
5
Treatment Planning
*
1
2
3
4
5
Documentation
*
1
2
3
4
5
Cultural Competence
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1
2
3
4
5
List three skills or qualities that you have to offer that will be beneficial in your work at Anomaly Therapy
*
List three things you hope to gain from your work as an Anomaly Therapy intern
*
Please list an area of growth - something you are aware needs improvement - that you would like to address.
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Please briefly describe your professional goals in clinical mental health counseling.
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Have you ever been charged or convicted of any felonies or ethical violations?
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Is there anything else you would like us to know prior to your interview?
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Reference 1
*
First Name
Last Name
Email
*
Reference 2
*
First Name
Last Name
Email
*
Statement of Accuracy and Authorization
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This form has been completed to the best of my ability, and I believe all answers to be true and factual. I understand that any false information or omission may disqualify me from further consideration for the internship and may result in my dismissal if discovered at a later date.
First Name
Last Name
Date
*
MM
DD
YYYY
