Practicum/Internship or Supervision Application Form

Practicum/Internship or Supervision Application Form

Please fill out all required fields and upload your relevant documents to complete your application.
Applicant's Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of CACREP-Approved University or College*
Major*
PracticumInternshipSupervision (You have already graduated and are working toward licensure in GA)
Preferred Start Date*

MonthDayYear
Date
Upload Supporting Documents (e.g., transcripts, resume, letters, etc.)

Cancelof
College/University Contact Person Name
Contact Person Title/Role
Contact Person Email
example@example.com
Contact Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Tell us about yourself: Why did you choose counseling? What related experience or education do you have? What are your long-term goals as a mental health professional?
When you click Submit, you will receive a copy of your submission to your email. If you would like to reach out to us right away, you can email Internship Coordinator Beth Wodzenski at B@orchardhumanservices.org, Internship Director Rashonda Clay-Douthit, LCSW at RCD@orchardhumanservices.org, or text Dr. Darleen at (470) 420-9994.
Please check this to agree for us to respond to your application and to provide links and dates for programs, courses, supervision, and workshops related to your professional development.
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