Alliance For Children Clinical Therapist Intern Application

Name:

First NameLast Name

Phone Number:

Area CodePhone Number

E-mail Address:

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Resume:

Upload a File

Picture (headshot with white background):

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Please use a headshot wit a white background

Driver's License/Passport/Identification Card (for the purposes of initiating a background check)

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Language(s):

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.

How many semesters are you able to commit to this internship

Other

Please indicate the degree program in which you are currently enrolled/pursuing:

Other

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?

If yes, please list degree requirement and/or licensure requirement:

Total Number of Hours Needed per Semester:

Desired Term(s):

Other

Desired Start Date:

Date

Expected Completion Date:

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

Location Preferred:

Rows	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?

Other

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.

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:

Other

Have you lived outside of the state of Texas within the last five (5) years?

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

Have you been involved in a child abuse investigation?

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

If "yes" to the above questions, please explain:

Signature

Date

Alliance For Children Clinical Internship Application