Internship Questionnaire
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What school are you affiliated with?
*
If you hold a professional license or certification, please provide the Degree Licensure, the issuing authority (such as the state board), the license number, and the expiration date. If no current degree, please enter N/A.
*
What is your internship supervisor licensure requirement?
*
LISW
LSW/LISW-S
LPC/LPCC-S
LCDCIII/LICDC-CS
MD/DO
Other
What is your desired training population(s)?
*
Adult
Youth
Non-Clinical
Other
What is your desired program(s)?
*
Any Available Program
Mental Health
Substance Use
Psych Services
Primary Care
Domestic Violence
Crisis
Support
Other
Mental Health:
*
Residential Group Setting
Community Support Services
Outpatient
No Preference/Any
Other
Substance Use:
*
Residential Group Setting
Recovery
Outpatient
Medication Assisted Treatment
No Preference/Any
Other
Psychiatry:
*
Nursing
Medication Assisted Treatment
Provider (Doctor, Physicians Assistant, APRN)
Other
Support:
*
988 National Suicide Lifeline
Call Center
Front Desk
Other
Other:
*
Finance
Human Resources
Facilities/Maintenance
IT
Business Administration
Other
Reference
Please provide the name of a Faculty Advisor we may contact.
*
First Name
Last Name
Faculty Advisor contact phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
About You
How did you learn about the internship program at TCN?
*
Why would you like to intern at TCN?
*
What are your goals post graduation?
*
Do you have any work, education, volunteer, or community service experience relevant to this internship?
*
What do you want to gain from this experience? (Skills, experience, etc.)
*
What is your learning style?
*
Schedule
When are you looking to start your internship?
*
-
Month
-
Day
Year
Date
What is your anticipated graduation date?
*
-
Month
-
Day
Year
Date
What hours/length of time is required for your internship? (EX: 2 Hours per day, 4 days a week, for 9 weeks) (EX: 300 Hours between September 10th and December 15th)
*
Please share any additional important information about your internship requirements and when you are looking to start:
*
When could you be available for an onboarding meeting with our Human Resources team?
*
Additional Information
Have you applied for, or are you a recipient of the Great Minds Fellowship Grant?
*
Yes
No
Have you applied for any other grants in relation to your internship?
*
Yes
No
If yes, provide details that TCN should know.
*
Do you have any feedback, questions, or additional information you would like to share?
*
Submit
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