Training Application

Training Application

Thank you for your interest in training at The Center! Upon submission of your application, you will be contacted by a representative to invite you to an upcoming virtual Open House. We look forward to seeing you!
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Résumé & Cover Letter (.pdf) *

Please upload your résumé, cover letter, and any supplemental documents in .pdf format here.
Cancel of
Are you currently enrolled in a graduate program? *

Yes No
If "yes," where?
What is your anticipated graduation date?
Are you eligible for practicum based on school requirements? *

Yes No
If "no," please list date of eligibility.
Are you currently a registered associate? *

Yes No
If "yes," what is your associate number?
When do you wish to start seeing clients? *
Are you able to conduct therapy in any foreign languages? If so, which? *
When would you like to see clients? *

Mornings Afternoons Weeknights Weekends
When would you like to meet for group supervision on a weekly basis? *

Monday, 2-4 PM Tuesday, 6:30-8:30 PM Wednesday, 3-5 PM Thursday, 3-5 PM Friday, 2-4 PM Saturday, 4-6 PM Sunday, 11-1 PM Sunday, 2-4 PM Open to any.
Have you completed Law & Ethics? *

Yes No
If "no," when do you expect to complete the course?
Have you received any personal counseling? *

Yes No
If "yes," for how long?
What counseling theories do you prefer? *
Please list 3 professional or academic references. *
Name - Phone - Email - Relationship
Are you a veteran? *

I am not a veteran. I am a veteran. I am a widow or widower of a veteran. I am the spouse of a 100% disabled veteran.
Have you ever been convicted by any court of a misdemeanor crime of domestic violence? *

Yes No
Have you ever been convicted by any court of a felony? *

Yes No
Have you ever had a Board licensing dispute? *

Yes No
If "yes" to any of the previous questions, please include an explanation below.
Certification

I certify under penalty of perjury that the information I have entered on this application is true and complete to the best of my knowledge. I further understand that any false, incomplete, or incorrect statements may result in my disqualification from the examination process or dismissal from volunteer employment with The Center for Professional Counseling (The Center for Individual & Family Therapy). I authorize all agencies to release any information they may have concerning the information provided on this supplemental application.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: