CPTC Internship Application — 2026

CPTC Internship Application — 2026–2027 Academic Year

Please complete all sections of this application. Submit the completed application along with all required supplementary materials. Applications are reviewed on a rolling basis. Incomplete applications will not be considered.
SECTION 1: Personal Information
Full Legal Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
SECTION 2: Academic Program Information
Graduate Institution
Degree Program & Title
Specialization / Concentration
Expected Graduation Date

MonthDayYear
Date
Credits Completed
Total Credits Required
Program Accreditation

CACREP-accredited (Clinical Mental Health Counseling)CACREP-accredited (Other specialty)COAMFTE-accreditedAPA-accreditedWSCUC / Regional accreditation onlyOther
If Other, please specify
SECTION 3: Faculty / University Supervisor
Faculty Supervisor Name
Title / Role
Credentials / Licenses
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Any Relevant Clinical Experience
SECTION 5: Relevant Coursework Completed
Relevant Coursework Completed

Counseling Theories & TechniquesEthics & Professional Orientation in CounselingMulticultural Counseling & Social JusticeHuman Growth & DevelopmentCareer Development & CounselingGroup Counseling & Group WorkAssessment, Testing & DiagnosisResearch Methods & Program EvaluationPsychopathology / Diagnosis & Treatment of Mental DisordersPsychopharmacologyCrisis Intervention & Trauma-Informed CareMarriage, Couple & Family CounselingSubstance Use & Addictions CounselingNeuroscience / Interpersonal NeurobiologyPsychodynamic / Psychoanalytic TheoryPersonality Theory / Object Relations
Additional relevant courses
SECTION 6: Internship Goals & Fit
Why are you interested in completing your internship at CPTC?
Please describe your interest in psychodynamic therapy and what draws you to CPTC's training model.
Describe your current theoretical orientation and how you see it relating to a psychodynamic framework.
What are your primary learning goals for the internship?
Describe a moment from your clinical training — whether in a counseling skills lab, or a classroom role-play — that was particularly meaningful to you. What did you learn about yourself as a clinician?
Are there specific client populations or presenting concerns you hope to gain experience with?
SECTION 7: Scheduling & Availability

Weekly Availability (Mark each cell with "Y" for available, "N" for not available, or "M" for maybe/flexible)

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Morning
Afternoon
Evening

Desired Start Date

MonthDayYear
Date
Desired End Date

MonthDayYear
Date
Total Hours Needed
Direct Hours Needed
Scheduling notes or constraints
SECTION 8: Professional Requirements Checklist
Professional Requirements Checklist

I am currently enrolled in a graduate counseling program and in good academic standing.I have successfully completed my practicum (minimum 100 hours, including 40 direct service hours).I have been approved by my academic program to begin internship.I hold (or will obtain prior to start) individual professional counseling liability insurance.I understand that I must disclose my intern status to all clients.I have read (or will read prior to start) the CPTC Internship Guide in its entirety.I am willing to complete a background check if required by CPTC or my academic program.I understand that CPTC's training model is grounded in psychodynamic theory, and I am open to learning within this framework.I understand the time commitment of 8–15 hours per week of in-person client sessions, plus 2 hours per week of group supervision.
Liability Insurance Provider
Policy Number (if active)
SECTION 9: Professional References
Reference 1 Name
Reference 1 Title / Role
Reference 1 Organization
Reference 1 Relationship to Applicant
Reference 1 Email
example@example.com
Reference 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Name
Reference 2 Title / Role
Reference 2 Organization
Reference 2 Relationship to Applicant
Reference 2 Email
example@example.com
Reference 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 10: Required Supplementary Materials
In addition to this completed application, please submit the following documents. Your application will not be reviewed until all materials are received.
Current CV or Resume (PDF, DOC, DOCX, JPG, PNG; Max 10MB)

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Unofficial Graduate Transcript (PDF, DOC, DOCX, JPG, PNG; Max 10MB)

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Letter of Endorsement from Academic Program (PDF, DOC, DOCX, JPG, PNG; Max 10MB)

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Liability Insurance Declaration Page (or proof of pending enrollment) (PDF, DOC, DOCX, JPG, PNG; Max 10MB)

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Background Check Results (if previously completed) (PDF, DOC, DOCX, JPG, PNG; Max 10MB)

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Optional: Writing sample, case conceptualization, or personal statement (PDF, DOC, DOCX, JPG, PNG; Max 10MB)

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SECTION 11: Applicant Attestation
[Paste attestation text from the application here]
Full Name (Typed Signature)
Date

MonthDayYear
Date
Signature (drawn)
Should be Empty:

CPTC Internship Application — 2026–2027 Academic Year

SECTION 1: Personal Information

SECTION 2: Academic Program Information

SECTION 3: Faculty / University Supervisor

SECTION 5: Relevant Coursework Completed

SECTION 6: Internship Goals & Fit

SECTION 7: Scheduling & Availability

SECTION 8: Professional Requirements Checklist

SECTION 9: Professional References

SECTION 10: Required Supplementary Materials

SECTION 11: Applicant Attestation