MCC Internship/Practicum Application Form

Clinical Intern Application Form
Applicant Information
Welcome to Milestones Counseling Center PLLC!

We're excited that you are interested in joining our team as an intern. We understand that you may not have all the details yet- just fill out what you have available to you at this time, but be as specific as possible. This application is simply the first step in getting to know you and how we can support your learning journey. If you have questions along the way, feel free to reach out. We look forward to learning more about you.

Please Note: All hours are completed from the MCC office in Crete, IL. Other local events may be required and some minimal travel may be necessary.
Demographic Information
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YesNoOther
March 2026April 2026May 2026June 2026July 2026August 2026September 2026October 2026Novemeber 2026December 2026January 2027February 2027March 2027April 2027May 2027June 2027Other
Name

First NameLast Name
Gender
Pronouns
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yes, please add me to the updates list.No, I do not want to be added to the updates list.
Internship/Practicum Information

Please answer all information as thoroughly and accurately as possible.
Start Date of Internship/Practicum

MonthDayYear
Date
End Date of Internship/Practicum

MonthDayYear
Date
Total # of Hours Required in Internship & Practicum
# of Hours Required Each Week
Please upload any information you have, from your school, about the hours and requirements of your internship/practicum program. Include anything with required direct hours, group hour requirements, etc.

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What is your preferred availability? (This is subject to change, we are just trying to get an idea.)
Tell us about your previous internship/practicum experience. If no previous experience, explain any other employment or volunteering experiences you have that have prepared you for this internship/practicum.
If applicable, what did you like about your previous experiences? What do you wish would have been different?
Why did you choose to apply for an internship at MCC?
What do you expect from us during your internship here?
What do you think we expect from you during your internship here?
What are your long term goals and ambitions?
What would you like to learn during your internship?
What are your related skills that can be used for the internship?
I'm not sure, I'd like to experience a little of everything.Children (6-12)Teens (13-17)Young Adults (18-24)Adults (25+)CouplesFamiliesGroup TherapyOther
Are there any specific populations or presenting concerns that you are passionate about working with?
Getting to Know You

We truly value authenticity, vulnerability, and a willing attitude over skill and knowledge at MCC. As an intern, it is your job to learn, so we know that you do not have all the answers. We much rather you say "I have no idea but I will find out" than make up something you think we want to hear. It's our job to help you learn the things that you do not know. We can't do that unless you allow yourself to be who you truly are, flaws and all. Below are some questions that will help us get to know more about you. These are not required, but we do ask that you answer at least a few.
What do you think will be your biggest personal challenge during your practicum?
Tell about a time you received constructive feedback that was hard to take. How did you respond and what did you learn from it?
If your best friend or mentor had to describe your weaknesses in three sentences or less, what would they be?
You may be in school, working, and completing a practicum (not to mention other life obligations). What routines do you have, or need, that will help you stay focused and organized?
What was the last thing you spent time learning, that did NOT have to do with work or school?
If you could design your ideal supervision experience, what would it look like? What would it include and what would it not include?
What is one misconception people have about you?
Is there anything else you'd like us to know about you, what you hope to accomplish through your practicum, etc?
Education Information
Current School Name
Current Grade Level/Degree
Previous Degree Information (School, Name of Degree, Date Awarded)
Graduation Date
Addiction CounselingBehavioral Health SciencesClinical Mental Health CounselingMarriage and Family TherapyPsychologyPublic HealthSocial WorkSocial Work- Advanced StandingMarketingOther
Special honors/Achievements
Please attach a resume and cover letter.

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Please attach school transcripts.

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Professional or Educational References
Name

First NameLast Name
Relationship
Company Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name

First NameLast Name
Relationship
Company Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please attach any letters of recommendation.

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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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Clinical Intern Application Form

Applicant Information

Demographic Information

Internship/Practicum Information

Getting to Know You

Education Information

Professional or Educational References

Acknowledgment