Alliance For Children Clinical Therapist Intern Application

Alliance For Children Clinical Internship Application
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
E-mail Address:*
example@example.com
Address:*

Street Address

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Postal / Zip Code
Resume:*

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THIS IS AN EDUCATIONAL INTERNSHIP: Internship REQUIRED to complete a degree at a college or university, to include independent study, courses and department field placements; standardly over one or two semesters.
How many semesters are you able to commit to this internship

1 semester max2 semesters max2 or more semestersOther
Please indicate the degree program in which you are currently enrolled/pursuing:*

Masters DegreeOther
Clinical Therapist Internship Program:

CLINICAL THERAPIST PROGRAM: MUST BE MASTER LEVEL OR ABOVE Offers both individual and group counseling services to confirmed victims of child abuse and their protective family members. Our clinical counseling staff work closely with clients to determine an individualized treatment program for each child. Counseling modalities utilized include Trauma-Focused Cognitive Behavioral Therapy through individual and group counseling, and Parent-Child Interaction Therapy.
School Information:
College / University: *
Department/Degree:*
Does your internship require your field supervisor to have a specific degree and/or licensure?*

YesNoUnsure
If yes, please list degree requirement and/or licensure requirement: *
Total Number of Hours Needed per Semester:
Length of Internship (if an educational internship):

Split Semesters (2 semesters)Block Semester (1 semester)
Desired Term(s):*

Fall 2025Spring 2026Summer 2026Fall 2026Other
Desired Start Date: *

MonthDayYear
Date
Expected Completion Date:

MonthDayYear
Date
Licensure Supervisor/ Field Liaison's Name:

First NameLast Name
Licensure Supervisor/ Field Liaison's Phone Number:

Area CodePhone Number
Licensure Supervisor/ Field Liaison's Email:
example@example.com
Clinical Internship Availability: Please note your schedule availability here. Clinical Department hours are traditionally Monday - Thursday from 9:00AM to 7:00 PM

Monday morningsMonday afternoonsMonday eveningsTuesday morningsTuesday afternoonsTuesday eveningsWednesday morningsWednesday afternoonsWednesday eveningsThursday morningsThursday afternoonsThursday eveningsFriday morningsFriday afternoonsOther

Location Preferred:

	Arlington	Fort Worth	Northeast (Hurst)
First
Second
Third

Please describe your interest in interning with Alliance For Children: *
Are you currently or have you ever received services through Alliance For Children?*

YesNoOther
If yes, please explain
Please note: A former client of Alliance For Children will not be considered for volunteer/intern/employment opportunities with the agency until two years have passed since completion of services.
References

Please list three (3) professional references that are familiar with your work life.
I authorize Alliance For Children to contact my personal references listed and understand that Alliance For Children will not be held liable for the release of this information.

YesNo
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email address:*
Relationship: *
Years Known:
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email address*
Years Known:
Relationship: *
Emergency Contact
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Relationship: *
Background Check Release
I grant permission to Alliance For Children to initiate, via the Department of Family and Protective Services' online self-service system, a Child Abuse/Neglect Central Registry and a Texas Department of Public Service Criminal history check as well as any subsequent checks so long as I am active with the agency. I attest that the information I provide online will be correct and that providing false information is a violation of the Texas Penal Code Section 37.10 and agree to update Alliance For Children with any changes to the information above. I am a prospective intern and consent to release information regarding criminal or abuse history to Alliance For Children. I agree to update Alliance For Children with any changes to the information above. I consent to release information regarding criminal, abuse, and/or sex offender registry information to Alliance For Children. I ACKNOWLEDGE I HAVE READ THE ABOVE AND INDICATE YES, I AGREE BELOW:*

Yes, I agreeOther
Have you lived outside of the state of Texas within the last five (5) years?*

YesNo
Have you ever been arrested or charged with a criminal violation of law? *

YesNo
Have you been involved in a child abuse investigation?*

YesNo
Have you used or sold illegal drugs within the past 5 years?*

YesNo
If "yes" to the above questions, please explain:
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Alliance For Children Clinical Internship Application