Counseling Internship Program Application
First Name
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Last Name
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Email
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Phone
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Address
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City
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State
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Zip Code
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Degree Program or Field of Study
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Name of College or University
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Projected Internship Start Date
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What days are you available?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How much time can you dedicate in a week?
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3 hours or less
3 to 5 hours
5 to 10 hours
10 to 15 hours
15 to 20 hours
20 or more hours
Do you have any past counseling or mental health experience?
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Yes
No
List and describe any past or current experience in the fields of counseling, mental health, or health and human service.
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Please add any comments or questions you might have.
SUBMIT
