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*

MonthDayYear
Date
Name*

First NameLast 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.
Cancelof
Are you currently enrolled in a graduate program?*

YesNo
If "yes," where?
What is your anticipated graduation date?
Are you eligible for practicum based on school requirements?*

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

YesNo
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?*

MorningsAfternoonsWeeknightsWeekends
When would you like to meet for group supervision on a weekly basis?*

Monday, 2-4 PMTuesday, 6:30-8:30 PMWednesday, 3-5 PMThursday, 3-5 PMFriday, 2-4 PMSaturday, 4-6 PMSunday, 11-1 PMSunday, 2-4 PMOpen to any.
Are you available to provide counseling in person and / or via telehealth?*

Available for both in person and telehealth.Available only for in-person.Available only for telehealth.
Have you completed Law & Ethics?*

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

YesNo
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?*

YesNo
Have you ever been convicted by any court of a felony?*

YesNo
Do you currently have any pending issues with the court?*

YesNo
Have you ever had a Board licensing dispute?*

YesNo
Have you ever had any disciplinary action levied against you by your training institution / graduate program?*

YesNo
If "yes" to any of the previous questions, please include an explanation below.
Are you fully vaccinated against Covid-19?*

YesNo
Technology Statement

Volunteer employment at The Center requires that counselors have foundational technological skills. Individuals must be familiar with Microsoft Word and cloud based services such as Google Drive and Dropbox. The Center will train counselors on the processes utilized in the course of their work as therapists but we are unable to support individuals who do not have these foundational skills.
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*

By signing above, I acknowledge that I have read and understand the technology statement and certification. Clear
Date*

MonthDayYear
Date
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