Clinical Internship Application
Applicant Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Phone Number
*
E-mail
example@example.com
Are you vaccinated?
Yes
No
Date of last TB Test
*
-
Month
-
Day
Year
Date
Date of last COVID Test
*
-
Month
-
Day
Year
Date
Date of last COVID Vaccination
*
-
Month
-
Day
Year
Date
Date of last livescan
-
Month
-
Day
Year
Date
Will you need any special accommodations to assist in your success at FSA?
Do you have any previous association with FSA?
Applying for:
*
Please Select
MFT Trainee
MFT Associate
SW Associate
PhD/PsyD Student
Graduate School
*
Program
*
Graduation (Anticipated Date)
*
Current Year Level
*
School Name
*
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practicum placement advisor
*
Associate Registration number (if applicable)
*
Have you ever received disciplinary action, been placed on probation, orterminated from an academic setting or clinical site? If yes, please provide an explanation of circumstances
*
Please Select
Yes
No
Have you ever been convicted of a felony or reported for sexual misconductwith a child or an adult? If yes, please provide an explanation of circumstances
*
Please Select
Yes
No
Previous Experience: (Please list number of hours completed)
Hours Completed
Children
Adults
Couples
Families
Groups
Languages Spoken
What are your practicum clinical hour requirements?
What is your current status in regards to your hours?
Personal- Please attach responses to the following questions:
1. Which FSA program(s) are you interested in working in?
*
2. Do you have any special areas of interest, training or areas you may want to learn more about?
*
3. What inspired your interest in pursuing this career?
*
4. Why would FSA be a good fit for you?
*
5. Do you have a preferred theoretical orientation? If so what makes this orientation appealing?
*
6. When are you available to begin a trainee/internship?
*
7. What days/hours are you available?
*
8. What are your long-term goals?
*
9. What do you hope to gain from a clinical experience at Family Service Agency of Burbank?
*
References
Please provide us 3 references
Reference 1 Name
*
First Name
Last Name
Title
*
Organization
*
Phone Number
*
Reference 2 Name
*
First Name
Last Name
Title
*
Organization
*
Phone Number
*
Reference 3 Name
*
First Name
Last Name
Title
*
Organization
*
Phone Number
*
Other Attachments
1. Please attach your resume.
2. Send us a copy of your graduate degree or intern number (if applicable), stating that you are in good standing and eligible for trainee/internship.
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