Cognitive Behavior Institute Internship Application

Cognitive Behavior Institute Practicum/Internship Application Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Graduate Program*

CounselingMSWClinical PsychologyMFTOther
Please select the names of your top three ideal supervisors. -- For more information, see the supervisors’ clinical biographies: https://www.papsychotherapy.org/resources/center-for-clinical-supervision-training*

Courtney Sonntag, LMFTLindsey Breznik, PhD, Licensed PsychologistRachel Hahn, LPCElizabeth Bendick, PsyD, Licensed PsychologistJennifer Snow, LPCAnthony Calvario, LPC, NCC, CGTJoy Harris, LCSW
For more information, see the supervisors' Supervision Biographies
Please select the course(s) for which you are seeking placement:*

PracticumInternship IInternship IIOther
What are the start and end dates of the entire period (MM/YYYY - MM/YYYY) for which you are applying?*
Please outline expectations for Group hour requirements of your program and which types of services qualify as Group hours.*
Please describe the expectations set forth by your university related to tele-health and tele-supervision (i.e. permits 100% telehealth hours, requires majority “in-person” direct hours, allows/limits tele-supervision) Note: these expectations may be listed in your course syllabus or Practicum & Internship handbook.*
Please describe your theoretical orientation: *

0/100
Please describe the populations with which you are hoping to work and gain support*

0/50
Please describe your personal goals for supervision (strengths and areas for growth)*

0/100
Please read and confirm:*

I understand that field placement is an educational experience. Therefore, I expect to be treating clients from various populations. I will utilize the formal (individual/group supervision) and informal (resources) supports at CBI to make my learning as diverse as possible.
Please upload your resume/CV*

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Please upload a Cover Letter*

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Please provide the name, e-mail, and phone number for two professional references:*
Please provide the Site Agreement/Memorandum of understanding for your university:*

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If selected, applicants will be required to submit the following clearances within one month of acceptance to secure a position.
- Certificate of Completion- Recognizing and Reporting Child Abuse: Mandated and Permissive Reporting in Pennsylvania (3hr)
- Criminal Background Check
- Pennsylvania Child Abuse History Certification
- FBI Fingerprint Clearance
Optional: Please provide the aforementioned clearances (completed within the past 6 months of application date):

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How did you hear about clinical field placement at Cognitive Behavior Institute?*
Other:
Should be Empty:

Cognitive Behavior Institute Practicum/Internship Application Form