Internship Application
Date:
Email:
Last Name:
First name:
Address:
Street number
Home phone:
City
State
Zip code
Cell phone:
Degree Program:
School:
Advisor/Placement Coordinator:
Phone or email:
Anticipated Date of Graduation:
Undergraduate Major:
Describe your interest in community mental health work:
Please list your first two choices of populations with which you are most interested in working:
1.
2.
Please note any physical limitations that require accommodation:
Are you willing to transport clients in a MHP van as part of your work? Yes
No
Have you ever been sanctioned, terminated, or excluded from any federally funded program?
Yes
No
If yes, please explain.
Have you ever voluntarily terminated from a federal program in this state or any other state?
Yes
No
If yes, please explain.
Have you been involved in an administrative repayment situation?
Yes
No
If yes, please explain.
Have you ever been convicted of an offense in a court of law? Yes No If yes, please give dates, details, and
penalties for each occurrence on an attached sheet of paper. An answer of “yes” to this question does not
constitute an automatic bar to an internship.
Signature:
Date:
(Please sign, scan and attach to email if sending electronically.)
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Please list all 1st year graduate field placements or practicums that have been part of your program
curriculum if applicable.
1. Agency:
Supervisor:
Phone:
2. Agency:
Supervisor:
Phone:
What do you see as your major strengths in working with people?
What do you see as your major weaknesses in working with people?
What do you see as the goal of therapy?
What are your long-term career goals?
If you are multilingual in what languages are you fluent?
To initiate the process, send: 1) Completed Application, 2) Resume & Cover Letter
3) Two Letters of Reference.
Electronic applications and supporting documents can be sent by email to:
[email protected]
or
Intern Coordinator
Mental Health Partners
1333 Iris Avenue, Boulder, CO 80304
Boulder, CO 80304
Or
Fax: 303.449.6029
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