Internship/Practicum Application

Personal Information

Legal First Name, Middle Initial and Last Name*

Please double check your spelling and include your full legal name. We will use the spelling provided for your background check.

Maiden Name if Applicable:

I identify my gender as:*

What is your race/ethnicity?*

Date of Birth*

Primary Phone Number*

Mailing Address*

City / State / Zip*

Email*

Enter Email Confirm Email

Please provide your preferred email address, this needs to be the address that is frequently used and checked.

Marital Status:*

Do you have children?*

Yes
No

Ages of children, if applicable:*

Do you have any medical history that is imperitive for us to know?*

Yes
No

Please share any medical alert information that we may need to know:*

Emergency Contact Name*

Emergency Contact Phone*

Relation to Emergency Contact*

Internship/Practicum Requirements

General interns and practicum students are asked to facilitate support groups at our center or in schools during their internship. Groups are held on Mondays and Thursdays from 6:30 to 7:30 p.m. Each student is asked to commit to facilitating a group for a minimum of six (6) months. Clinical interns are asked to see clients at least one evening per week until 8:00 p.m. Each clinical intern must hold and provide proof of malpractice insurance and commit to at least eight (8) months of service.

University or school attending*

Current year based on credit hours?*

Are you seeking a clinical internship?*

Yes
No

What is the length of your internship/practicum? How many hours does your internship or practicum require for completion?*

We require all incoming interns and practicum students to complete at least 100 hours at Calm Waters.

Criminal History

Have you ever been charged with, plead guilty to or been convicted of a criminal offense?*

Yes
No

If yes, please explain*

We require all volunteers, interns and practicum students to complete a background check before starting their work. Are you a legal U.S. citizen with a valid license and social security number?*

Yes
No

What connects you to our mission?

What employment or work experience do you feel would help you relate to the Calm Waters mission?*

Please give us the top three reasons you would like to complete your practicum/internship with Calm Waters:*

Internship/Practicum Application

Calm Waters Internship/Practicum Application

Step 1 of 2

Personal Information

Internship/Practicum Requirements

Criminal History

What connects you to our mission?

Reference #1 Information

Reference #2 Information

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