Black Brain Campaign Internship
APPLICATION
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Will any documentation submitted in connection with this application be received in a name other than the name under which you are applying?
*
Please Select
yes
no
If Yes, please list the other name or names below. (Submit a copy of the legal document evidencing the name change (i.e., marriage certificate, divorced decree or court order)
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Accredited School Where Degree is Being Obtained At:
*
Address of School
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Graduation
*
-
Month
-
Day
Year
Date
COAMFTE Approved Post-Graduate Program:
*
Have you been convicted (found guilty, pled guilty or plead nolo contendere), received probation without verdict or accelerated rehabilitation disposition (ARD), as to any criminal charges, felony or misdemeanor, including any drug law violations? Note: You are not required to disclose any ARD or other criminal matter that has been expunged by order of a court.
*
Please Select
yes
no
Do you currently have any criminal charges pending and unresolved in any state or jurisdiction?
*
Please Select
yes
no
Do you have any mental or physical condition that would prevent you from practicing counseling with reasonable skill?
*
Please Select
yes
no
Have you ever violated standards or professional practice or conduct?
*
Please Select
yes
no
Do you currently engage in or have you ever engaged in the intemperate or habitual use or abuse of alcohol or narcotics, hallucinogenic or other drugs or substances that may impair judgment or coordination?
*
Please Select
yes
no
Have you ever had provider privileges denied, revoked, suspended, or restricted by a Medical Assistance agency, Medicare, third party payor or another authority?
*
Please Select
yes
no
Have you ever had practice privileges denied revoked, suspended or restricted by a hospital or any health care facility?
*
Please Select
yes
no
Have you ever been charged by a hospital, university, or research facility with violating research protocols, falsifying research, or engaging in other research misconduct?
*
Please Select
yes
no
IF YOU HAVE ANSWERED “YES” TO ANY QUESTIONS FROM 1 THROUGH 9, PLEASE ATTACH AN8 1⁄2 X 11 SHEET OF PAPER GIVING FULL DETAILS. INCLUDE COURTHOUSE CERTIFIED COPIES OF ANY DOCUMENTS EXPLAINING THE SITUATION, IF APPLICABLE.
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Supervisor Information
Name of your Supervisor
Supervisor Name
*
First Name
Last Name
Supervisor Telephone Number
*
Please enter a valid phone number.
Supervisor Email Address
example@example.com
Date of Supervision (Start)
-
Month
-
Day
Year
Date
Availability
Complete the following chart with your availability. These times will include a minimum of eight (8) direct hours (counseling), individual supervision is a minimum of 1 hour per week.
Client Contact Hours: Total of 8 hours per week
*
Individual Group/Individual Supervision: 1 Hour per week
*
Documentation
The following information must be submitted along with your completed application for review:
Copy of Bachelor's Degree
*
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Transcripts
*
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Child Abuse Clearance
*
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PA State Criminal Background Check
*
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FBI Clearance (If you have NOT lived in PA for the past 10 years)
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General Liability Insurance
*
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Resume/ Curriculum Vitae
*
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Headshot
*
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Professional Bio
*
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Professional Reference #1
*
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Professional Reference #2
*
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Identification Card
*
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VERIFICATION
I verify that that this application is in the original format as supplied by the Black Brain Campaign Licensure Education Assistance Program© and has not been altered or otherwise modified in any way. I verify that the statements in this application are true and correct to the best of my knowledge, information and belief. I understand that false statements that are made may result in suspension, revocation or denial of this licensure program.
Signature
*
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