• Grad Student Placement Application

    Grad Student Placement Application

    Community Healing And Mental Health Project (CHAMP)

  • Personal Information

  • Date Of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Academic Information

  • Expected Graduation Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you need this internship for course credit?*

  • Availability

  • Preferred Start Date *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Weekly Availability*
    Rows
  • Are you able to attend and facilitate youth programming on the 1st Thursdays (5-8PM) in Fort Worth, and attend occasional Saturday community pop-ups.*

  • Internship Track

  • Select the Track(s) You Are Interested In*

  • Skills & Experience

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  • Background Requirements

  • Have you ever been convicted of a felony?*
  • Do you have reliable transportation?*
  • Are you willing to undergo a background check?*
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  • Clinical Applicants Only

  • What theories or modalities are you most familiar with?*

  •  CHAMP Mobile Mental Wellness Unit Participation

  • Are you comfortable supporting services inside the Mobile Mental Wellness Clinic*
  • Are you comfortable interacting with youth in schools, community centers, and apartment complexes?*

  • Media Release

  • Do you consent to being photographed/video recorded for CHAMP events, social media, and documentation?*

  • Liability & Confidentiality

  • *

  • Preferred Reimbursement Method

  • Please select how you would prefer to receive any applicable internship-related reimbursements.*

  • Please enter the payment information associated with your selected method (e.g., Cash App $Cashtag or Zelle phone number/email address). Please double-check your information for accuracy.

  • Graduate Internship Expectations

  • As a Graduate Intern with CHAMP, I understand and agree to:*
    • Creating and designing content.
    • Engaging on CHAMP social media platforms.
    • Sharing, liking, and commenting on CHAMP posts to increase community reach.

  • Signature

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: