Grad Student Placement Application
Community Healing And Mental Health Project (CHAMP)
Personal Information
Full Name
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First Name
Last Name
Preferred Name
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Date Of Birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Academic Information
College/University
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Department / Program
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Please Select
Bachelor of Social Work (BSW)
Master of Social Work (MSW)
Counseling (School / Professional / Clinical Mental Health)
Public Health (MPH)
Education
Other (Please specify)
If Selected "Other" Please Specify
Current Degree Level
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Please Select
Undergraduate
Graduate
Doctoral
Expected Graduation Date
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Month
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Day
Year
Date
Internship Course Instructor/Advisor Name
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Instructor/Advisor Email
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example@example.com
Do you need this internship for course credit?
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Yes
No
Semester you are applying for
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Please Select
Fall Semester
Spring Semester
Summer Semester
Number of hours required
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Availability
Preferred Start Date
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Month
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Day
Year
Date
Preferred End Date
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Month
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Day
Year
Date
Weekly Availability
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Rows
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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.
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Yes
No
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Internship Track
Select the Track(s) You Are Interested In
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Clinical/Counseling Track (youth counseling, SEL facilitation, mobile mental wellness unit)
Research & Data Track (mental health assessments, program evaluation, dashboards)
Community Engagement Track (outreach events, resource fairs, partnerships)
Communications/Media Track (content creation, social media, video editing, storytelling)
Administrative/Program Management Track (scheduling, operations, documentation)
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Skills & Experience
Upload Your Most Recent Resume
*
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Upload a recent headshot
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Upload Your School’s Internship Requirements/Handbook (if applicable)
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Describe any previous experience related to mental health, youth development, or community engagement.
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What specific skills or strengths do you bring to CHAMP?
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What do you hope to learn or gain from your internship experience?
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Background Requirements
Have you ever been convicted of a felony?
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Yes
No
If yes, please give a brief explanation
Do you have reliable transportation?
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Yes
No
Are you willing to undergo a background check?
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Yes
No
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Clinical Applicants Only
What theories or modalities are you most familiar with?
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CBT
DBT
Trauma-Informed Care
Solution-Focused Therapy
Play Therapy
Motivational Interviewing
Other
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CHAMP Mobile Mental Wellness Unit Participation
Are you comfortable supporting services inside the Mobile Mental Wellness Clinic
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Yes
No
Are you comfortable interacting with youth in schools, community centers, and apartment complexes?
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Yes
No
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Media Release
Do you consent to being photographed/video recorded for CHAMP events, social media, and documentation?
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Yes
No
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Liability & Confidentiality
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I agree to follow Health Insurance Portability and Accountability Act (HIPAA) privacy standards.
I agree to maintain strict client confidentiality.
I understand I am expected to act professionally at all CHAMP events.
I understand that clinical interns will be supervised by a licensed mental health professional.
I understand this application does not guarantee placement.
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Graduate Internship Expectations
As a Graduate Intern with CHAMP, I understand and agree to:
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Participate in facilitating the First Thursday Community Healing Event at the MLK Center on the first Thursday of every month from 5:00 PM–8:00 PM.
Participate in a minimum of two (2) and a maximum of two (2) Saturday community pop-up events during your internship placement.
Participate in CHAMP's monthly social media campaign by:
Creating and designing content.
Engaging on CHAMP social media platforms.
Sharing, liking, and commenting on CHAMP posts to increase community reach.
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Signature
Applicant Signature
*
Date Signed
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Month
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Day
Year
Date
Submit
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