TMH Internship Application
Pre-screen Questions:
Are you currently enrolled in a Bachelor's or Master's level clinical program?
Yes
No
Can you commit 15-20 hours per week to this internship?
Yes
No
Are you able to provide clinical services virtually, in-person, and in the community settings?
Yes
No
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Personal Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by (optional):
Resume
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Availability
Available Start Date:
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Education
Highest Education Obtained:
Bachelor's Degree
Master's Degree
Other
University Name:
University Name:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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University Field Instructor/Liaison Information:
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Clinical Experience:
Do you hold any relevant certifications (e.g., EMT, CPR)? If so, please list them:
Have you completed any relevant trainings (e.g., crisis intervention, cognitive behavioral therapy)? If so, please list them:
Skillsets: (Please tell us about your skills and talents relevant to clinical work, such as communication, active listening, empathy, etc.)
Direct Services Completed: In the table below, please list the types of direct services you have provided (e.g., individual therapy, family therapy, groups, workshops, case management, community support) and the approximate length of time you spent in each area.
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References:
Please provide contact information for three references, preferably from the clinical field:
Reference 1: Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2: Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3: Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Internship Focus:
What is your desired focus within the internship?
Direct Service
Administrative and/or Non-clinical Direct Service
Academic Internship Requirements
Answer if your school requires this internship
Length of Internship: (e.g., Semester, Year)
Required Hours per Week:
Breakdown of Direct vs. Non-direct Hours:
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