BHA Student Interest Form
We are so excited that you are considering BHA for your program experience! Completion of this form is the first step in expressing interest. Once received, a member of our team will review and contact you with more information.
Contact Information: Please include Full Name, Phone Number, and Email
What is the name of your school?
Who is the best contact person at your school for this program? Please provide their name, role, and contact information (email and/or phone number).
What type of program are you enrolled in?
MD
DO
PA
NP
Psychiatry
Psychology
MSW
RN
LPN
MA
Other
What specialty are you interested in for this experience?
How many total hours, and over what length of time? Please include dates for the experience and if the dates are flexible.
What credentials are required of your preceptor?
Are you able to complete the experience at any BHA clinic? If no, please list your preferred clinics.
Completion of this form is the first step in expressing interest. Our team will do everything possible to place you with a preceptor. However, this form does not guarantee a placement at BHA.
I agree
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