CTG Intern Application Form

Name:*

First NameLast Name
Semester and Year of Practicum/Internship for which you are applying (If applying for an Associate position, please note)*
Position *

LPC InternMFT InternTherapist- Temporary LicenseTherapist- Fully Licensed
University and Program in which You are Currently Enrolled*
Expected Graduation Date *
Date of Birth

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:*
Twitter Handle
Instagram Handle
Facebook Url
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Picture *

Upload a File

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Upload Resume:*

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Upload Transcript*

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Upload sample of your academic work. Quick Reference Guides (QRGs) are preferred.*

Browse Files

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Reference Letters

Please Note: If needed, you may upload a blank page to this section if you cannot immediately provide references. Please make a note here, if that is the case, and you may send your letters when you receive them. *Reference letters are due within one week of submitting application.
Upload Reference Letter 1*

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Upload Reference Letter 2*

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How were you referred to us?*
Why do you want to intern/work with Refocus Behavioral Health ?*
What makes you a fit for our practice?*
Please list the populations with which you want to work:*
What are your internship/practicum goals?*
What led you to the field of counseling?*
What do you see yourself accomplishing at Refocus Behavioral Health*
What do you see yourself contributing to Refocus Behavioral Health?*
What do you see as your greatest strengths and why?*
What do you see as your greatest areas for growth and why?*
Please describe a time you have been faced with a problem and how you resolved it.*
Please describe a time in which you had to adapt to changes around you.*
Do you have any concerns to be addressed for practicum or internship at Refocus Behavioral Health?*
How do you handle stress?*
Please check any responsibilities with which you may have concerns. Please explain checked items in the below box*

Pursuing additional trainingPursuing additional reading to learn/improve skillsPursuing additional needed supervisionReturning calls from clientsInitiating calls to new clientsKeeping up with your own scheduleFollow through with responsibilitiesKeep record of hoursProactively learning new skillsProactively doing researchSeeing new or different populationsFollowing directions and/or receiving constructive criticismMaking corrections or adjustments when advised to do soHandling stressful situationsHandling own stressBalancing scheduleWorking at the Mt. Juliet OfficeOther
Please explain any of the above concerns. Also please make note of any general concerns or questions you may have.
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