Application Questionnaire

Application Questionnaire
Name

First NameLast Name
Email
example@example.com
Practicum StudentIntern/AssociateLPCLCSWLMFT
School Program/University:
Supervisor’s Name and Credentials:
Contact information for your supervisor:
1. Please indicate your desired schedule that you can be expected to work.
Mondays time to time
Tuesdays time to time
Wednesdays time to time
Thursdays time to time
Fridays time to time
Saturdays time to time
2. How many total hours a week would you like to work?
Children (3- 10)Adolescents (10 -13)TeenagersYoung AdultsMiddle-AgedRetirement AgeElderlySpecial NeedsIndividualsCouplesFamiliesGroupsOther
4. Please list the types of issues you like to work with in counseling and any areas of specialty.
5. Please share why you are drawn to these clients and these areas of specialty.
6. Please list any particular types of clients or issues that you feel strongly about NOT working with.
7. How do you intend to schedule your sessions? How long will they last? Do you plan on scheduling breaks? Please describe:
8. What theories and interventions do you rely on as a counselor?
9. What do you believe are your strengths that make you good at counseling?
10. Share about a time you had a client (or other person) get upset with you and explain what happened.
11. What is the best compliment you have ever received from a client or a professor?
12. What do you personally believe is the strongest benefit to clients seeking counseling?
13 . How do you think I should handle it if a client reports to me they have had a bad experience with you in and / or out of session?
14. Which of any of the Licensing Board Rules do you disagree with or struggle with and why?
15. What do you feel is the benefit of your profession having a Code of Ethics?
16. Please share your personal thoughts on seeking continuing education for yourself and what you most desire from the trainings you attend.
17. What are some of your professional goals that you are pursuing for the next 1-3 years?
18. What strategies will you employ to try to generate new clients? How much support do you anticipate needing from Olive Branch?
19. What are you most worried about when entering into a relationship with Olive Branch?
20. What are your thoughts on offering services in addition to therapy sessions (ex. Workshops, groups, classes, etc) What might you be able to contribute?
Please do your best to answer these scenario questions and indicate how you would handle it.
21. If you have been working with an insurance client for quite some time and they let you know they need to miss the appointment but are perfectly fine with you going ahead and billing their insurance for the session, what is your response?
22. If a client asks you to hold off billing their insurance but would like to continue paying their $15 copay for sessions, what is your response?
23. If your longtime client asks you to meet them at Starbucks for their session so they can get to their other errands and appointments on time, what is your response?
Please use the space below and feel free to share any other information you would like me to know. You may also write down any questions you would like me to answer for you.
Should be Empty:

Application Questionnaire

1. Please indicate your desired schedule that you can be expected to work.

Please do your best to answer these scenario questions and indicate how you would handle it.