Rocky Creek / Discovery Trail Internship Application [040416]

INTERNSHIP APPLICATION All individuals interested in an INTERNSHIP with The Comfy Place must complete this application in full. Items marked with an asterisk require a response.
Applicant Information
Today's Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Mobile Phone*
Work Phone
E-mail Address*
School Attending*
Please indicate which school you are attending
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Degree Being Sought*
Please indicate the degree you are currently seeking
Anticipated Graduation (mm/yy)*
Please indicate your anticipated graduation date
Advisor Name*
Advisor Phone*
Advisor E-mail Address*
Semester wanted for Internship (check all that apply)*

SpringSummerFallWinterOther
What is your availability or desired days/times to work? [check all that apply]*

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PMSpecial EventsOther
Are you available to see clients during evenings and weekends, as these times are often requested in our private practice setting?
Internship Type [check all that apply]*

Part-Time [8-20 hours/week]Full-Time [21-40 hours/week]Unsure/FlexibleOther
Number of credits wanted for internship:
Education
High School*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From (mm/yy) - To (mm/yy)*
College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From (mm/yy) - To (mm/yy)
Degree Earned
Previous Employment or Experience
Company
Job Title
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor:
Responsibilities:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Reason for Leaving:
May we contact your supervisor for a reference?

YesNo
Please Describe Your Goals for an Internship
In seeking an internship with The Comfy Place, please describe your understanding of the services The Comfy Place provides and how this aligns with your own goals, strengths, and learning. How does it fit into your personal goals now, and your future career goals?*
What specific goals are you hoping to accomplish during your internship? Are there certain areas you would like to focus?*
Since our interns are required to work in such close proximity to staff members and clients, what qualities do you possess that will allow you to excel within, and contribute to, the team structure?*
One of our objectives is to offer mental health services to individuals; and work to eliminate the stigma that often surrounds the diagnosis and treatment of mental illness. What are your opinions about mental illness? What qualities do you possess that make you a good candidate for working in this type of environment? Will you be able to abide by the confidentiality requirements that make the office a safe place for our clients?*
Is there any other additional information that you would like to share with us? Are there any qualities that you possess that were not addressed in this application that you feel are important to share?*
How did you find out about our internship program?*
Please attach a copy of your resume (Microsoft Word or PDF only)*

Browse Files

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Please indicate your availability for an interview:*
BY TYPING YOUR NAME IN THE BOX BELOW, YOU CERTIFY THAT ALL OF THE INFORMATION THAT YOU HAVE PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT.*
Thank you for taking the time to complete our Intern Application! We will be in touch shortly. If you have any questions, please don"t hesitate to contact us at: info@thecomfyplacellc.com
www.thecomfyplacellc.com
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