Clinical Staff Application

Clinical Staff Application

Therapists/Counselors - Interns - Volunteers
Applicants are considered without regard to race, color, sex, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or disability.
Position Applying For*

Therapist/CounselorIntern, Master's LevelIntern, Bachelor's LevelVolunteer - Downingtown office only
ALL APPLICANTS
Full Name*

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Email Address*
example@example.com
Date of Birth

MonthDayYear
Social Security Number
Emergency Information
Emergency Contact Name*
Emergency Contact Phone #*
Format: (000) 000-0000.
Relationship to Emergency Contact*
How were you referred to The Peacemaker Center?
Why do you want to work at The Peacemaker Center?
Do you have work experience in the field of counseling or other service-related fields?
List any professional or civic organization to which you belong.
When are you available to start?*
Which office locations do you prefer to work out of?*

Audubon - 778 Sunnyside AveDowningtown - 368 W Uwchlan AveFt Washington - 500 W Office Ctr Dr, #100Kennett Square - 202 S Willow StNew Holland - 107 South Hoover StPaoli - 73 Plank AveWest Chester - 312 W Union St

Which Days and Times during the week are you available?

Rows	Mon	Tue	Wed	Thu	Fri	Sat	Sun
Morning (9am-1pm)
Afternoon (1pm-5pm)
Evening (4pm-8pm, unavailable for Volunteers)

CRIMINAL HISTORY / CHILD ABUSE CLEARANCE
A Criminal History Clearance, or FBI Clearance for non-Pennsylvania residents and a Child Abuse Clearance is required as part of the application process. Do you have any objection?*

NoYesOther
Were you ever convicted of a criminal offense (including driving under the influence (DUI) anywhere (any city, state, or locale) or do you have a criminal charge against you now pending? (omit minor traffic violations and anything prior to your 18th birthday)*

NoYesOther
If yes above, provide details and a copy of the docket. Convictions of a criminal offense will not necessarily prohibit you in all cases. Each case is considered on its own merits.*
Have you ever had a Restraining Order issued against you? If yes, provide details.*
Have you or any other adult living in your household had a Protection from Abuse order issued against them? If yes, provide details.*
RESUME
Your Resume Can Be Uploaded Here

Cancelof
REFERENCES

Enter Four References - No Relatives Please

I authorize the references listed above to furnish The Peacemaker Center with any relevant information that may be required to arrive at a volunteer/employment decision. I hereby release The Peacemaker Center and the references listed from any liability arising from their receiving or giving information about my history, qualifications, or suitability for volunteering/working at The Peacemaker Center.
INTERNS
We provide flexible practicum and internship opportunities to students in clinical mental health counseling, marriage & family therapy, and social work programs that can be structured around a student's course curriculum. We only accept candidates who will be doing both practicum and internship at The Peacemaker Center.
Enter Practicum Start Date
Enter Practicum End Date
Enter Internship Start Date
Enter Internship End Date
INTERNS indicate specific experiences you would like to gain through your internship with The Peacemaker Center. Include any specific requirements or supervision hours needed.
EDUCATION, TRAINING, EXPERIENCE

Are you currently a full-time student? If so, what is your current pursued major?
Student Level

FreshmanSophomoreJuniorSeniorGraduate StudentOther
Describe your long-term career goals.
VOLUNTEERS
Indicate your areas of interest/work preference

Office HelpWork on Individual ProjectFacility OrganizationLandscapingSocial MediaResearchPhotographyFundraisingBuilding MaintenanceMarketingOther
Mark anticipated dates of Commitment

OnceWeeklyBi-WeeklyMonthlyOngoingUnsureSpecial projects only
List additional volunteer experience.
List recent employment experience.
List your interests, skills, and hobbies.
AGREEMENT
All Peacemaker Center staff, paid and unpaid, are required to sign an agreement regarding confidentiality. Your signature below indicates that you will agree to keep confidential all information learned regarding clients while performing your duties at The Peacemaker Center.

I certify that all information in this application is correct and complete, and I understand that any false statement or omission of material/fact may disqualify me from further consideration at The Peacemaker Center.
Date

MonthDayYear
Date
Signature*

Sign with your mouse, stylus, or finger
All information received on this application will be handled with the utmost care and confidentiality.
Should be Empty:

Rows	Name	Location - City & State	Year Graduated	Degree/Certification Earned
1
2
2

Rows	Name	Location - City & State	Year Graduated	Degree/Certification Earned
1
2
3

Rows	Name	Location - City & State	Year Graduated	Degree/Certification Earned
1
2
3
4

ALL APPLICANTS