Intern Application Form

Internship Application

2025
Serenity Zone Therapy is a 100% virtual practice who has worked with CACREP accredited and CACREP aligned programs throughout New York State. We currently have two active supervisors who provide weekly supervision through HIPAA Compliant video platforms, Zoom and Google Meets.

Please Note: Failure to complete the application with required information will result in removal of application from consideration for internship.
Applicant Information
Name*

First NameLast Name
Age*
Gender*

MaleFemaleNon Binary
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you bilingual?*

YesNo
If You Answered Yes, Please Identify the Language Below and if You are Comfortable Conducting Sessions and Written Communication in the that Language. If No, enter N/A*
Which of the following do you have function interest that will account for Non-direct hours, which are a requirement of all graduate student interns?*

Social Media (including Instagram, TikTok, Facebook)Blogging (Please include a blog sample down below if interested in this task)Community Outreach (including reaching out to local schools and doctor's offices to introduce the practice)Creating and presenting case presentations during peer to peer meetingsAssisting with organizing the Digital Resource Manual
Blogging Sample

Cancelof
Start Date of Internship (Availability)*

MonthDayYear
Date
End Date of Internship (Projected)*

MonthDayYear
Date
Are you willing to work during weekends and holidays?*

YesNo
How did you hear about Serenity Zone Therapy, LCSW PLLC*
What are things you want to learn during your internship?*
What are your professional goals and ambitions?*
If you had to present yourself with a 90 second time limit, what would that look like?*
Education Information (Graduate School Attending)
School Name*
Degree*
Years attendend*
Academic Advisor Name and email:*
Special honors/Achievements*
Employment History (Current Company, if employed)
Company Name*
Position/Title*
Supervisor's Name and Contact Info:
Duration (number of months)*
What is your role and responsibilities in that company?*
References

Please Provide at least 3 reference: One Academic, Two Professional as we will be reaching out to them
Academic Reference: (Professor, Academic Advisor)*

First NameLast Name
Company Name and Role*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Professional Reference: (Supervisor, Colleague that can speak to your work directly)*

First NameLast Name
Company Name and Role:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Professional Reference 2*

First NameLast Name
Company Name and Role*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Resume, Cover Letter and Headshot

Please upload your most recent Resume, Cover Letter, and Headshot down below
File Upload*

Cancelof
Please provide some availability for scheduling a Zoom Interview within the next couple of weeks.*
Acknowledgment
I hereby certify that all information I provided in this document is accurate and true to the best of my knowledge.

I confirm that I have read and understood the reason why the Personal Information Collection Statement is required.

I understand that data collected from this form will be used for recruitment and evaluation purposes only. All data will be strictly confidential.
Applicant's Signature

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Date Signed

MonthDayYear
Date
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Internship Application

Applicant Information

Education Information (Graduate School Attending)

Employment History (Current Company, if employed)

References

Resume, Cover Letter and Headshot

Acknowledgment