Family Attachment & Counseling Center
18322C Minnetonka Boulevard, Deephaven, MN  55391
tel: 952-475-2818 fax: 952-475-3356

Internship/Practicum Application 

Name:						Current Date:

Position Seeking:    

Anticipated Start Date:            		Requested hours per week and total:

I. Contact information 
	
	Home Address:

	Phone (home):					Phone (other):
	E-mail:
II. Educational Background
	Highest degree held in a mental health field:
	Current Educational Institution:
	Degree in progress:
	Dissertation/master’s project title/topic and current status:

	Past Academic Work:
		Graduate School/University (Degree/Date/Major):

		Undergraduate College/University (Degree/Date/Major):

Licensure/Certification: Some applicants may be licensed or certified at the master’s level.  If you are, please list any licenses or certifications in mental health fields which would allow you to practice counseling or psychotherapy.

III. Summary of Practica Experience:
Please describe any previous practica including total number of hours and populations served:

	Describe your position within each practicum:

IV. Other Clinical Experiences – Please describe related settings and activities that are not described in the practica section.

V. Assessment/Test Administration – Please indicate all instruments you have used in your assessment experiences.

VI. Report Writing - Have you completed integrated psychological reports?  If so, approximately how many for adults and how many for children/adolescents? 

VII. Professional Conduct  (If you answer yes to either of these questions please attach an explanation on a separate sheet of paper.)

Has disciplinary action, in writing, or any sort ever been taken against you by a supervisor, educational or training board, health care institution, professional association, or licensing/certification board?

Have you ever been suspended, terminated, or asked to resign by a training program or practicum site?

VIII. Goals/Interests (Please respond to these questions on a separate sheet of paper limiting your answers to 500 words or less.)

1.	Please provide an autobiographical statement (There is no “correct” format for question.  Answer this question as if someone has asked you, “tell me something about yourself.”)

2.	How do you envision our internship/practicum site meeting your training goals and interests? 

3.	The Family Attachment Center is committed to working with children and families. Please describe your experience with and your interest in working with children and families.

4.	Please describe your current short and long term career plans.

5.	The placement at Family Attachment Center is very demanding. It is typically 20 hours per week requiring adaptability in scheduling. Please address your ability to meet this schedule.

6.	The Family Attachment Center is a Christian mental health center and many clients are seeking counseling in issues related to spirituality. Please address your comfort level with integrating spirituality and psychotherapy. Feel free to share pertinent parts of your spiritual journey.

IX. References – Please provide three professional references (include name, phone number and relationship).

1.	

2.

3.	

X. Additional information – Please attach a copy of your resume, graduate school transcript (unofficial OK), and a writing sample, preferable a psychological report if available.

Thank you for your interest in the Family Attachment & Counseling Center.  
We appreciate your effort is completing this questionnaire.