The Pivot Clinical Collective

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

State of residence during internship

We are only accepting mental health counseling interns in the states listed at this time.

University / Institution

Registered Interns: list the institution where you completed your graduate program.

Program Track

Clinical experience contact, faculty advisor, or qualified supervisor: full name

Please enter their full name and credentials

Clinical experience contact, faculty advisor, or qualified supervisor: University email

Please enter the University email

Which program level are you seeking to obtain hours at this time?

List any additional specifications on hours/type of service exposure you must have to meet your internship requirements

List any specifications on educational credentials required for your supervisor

E.g., MS in Counseling required

Which cohort are your applying for?

Which year are you applying for?

How many DIRECT hours are you available each week?

How many INDIRECT hours are you committed to getting each week?

Which days are you available to see clients?

Typical hours you are willing to work during the week?

Which day and time are you expected to meet for your WEEKLY GROUP Supervision (this is your weekly supervision with your University Faculty and Practicum/Internship class)?

Indicate Group Supervision Day and Time (e.g., Monday's 4PM-9PM; Tuesday's 8PM-10PM, etc..)

Upload resume/CV, cover letter, clinical experience handbooks, etc.

Please provide all relevant documentation for the selection and placement process as required by your university.

Which professional development are you most interested in attending/learning about in the future?

How did you hear about Just Pivot Wellness's Pivot Clinical Collective?

I _____________________ attest this information is true and accurate.

Please verify that you are human