Application for Counselor Employment

Licensing Information

To add additional lines, please click the plus sign to the right of the line.
Please list the information for your license(s) below:(Required)
Type of License
State
Date of Issue
Expiration Date
 
Do you have a license pending?(Required)
Have you ever had a malpractice complaint/claim/suit filed against you?(Required)
Have you ever been denied a professional license and/or certificate?(Required)
Have you ever voluntarily surrendered a professional license or certificate?(Required)
Have you ever been convicted, pled guilty, or nolo contendere to any misdemeanor or felony other than juvenile offenses or minor traffic violations?(Required)

Education and Training

Earned Degrees(Required)
Please list information for earned degrees (undergraduate and graduate):
Degree Earned
Educational Institution
Date Received
 
Continuing Education, Training and Certifications
Please list recent Continuing Education Units, trainings, certifications below:
CEU, Training or Certification
Date
Conference or Presenter
 

Supervision Experience

Please list the information regarding your experience of supervision below:(Required)
If you have yet to receive supervision, you may skip the remainder of this section.
Name of Supervisor
Supervisor's Credentials
Supervisor's Therapeutic Model
Duration
# of Hours
 
May we contact your supervisors?(Required)
If yes, please provide contact information, including email addresses below:
Name
Email
Phone Number
Supervisor Position
 

References

Please provide at least three (3) references, including email address and phone number, who can speak to who you are as a mental health counselor intern or marriage and family therapist intern. Please include at least one graduate program professor and, if applicable, at least one supervisor as references. A character reference may be included as one of the three.(Required)
Name
Email
Phone Number
Reference Type
 

Didactic Counseling

Were you required to participate in didactic counseling (i.e. personal counseling for the purposes of counselor formation and learning) as a part of your graduate program?(Required)

Theoretical Orientation

Faith Integration

Communication Style

Services Capacity

To add additional lines, please click the plus sign to the right of the line.
Are there any days or times of day that you are not available to provide counseling services?
Day
Time
 

Resume

Please upload your resume.
Max. file size: 256 MB.

If you have further questions, you are welcome to contact our Clinical Director, Jessee Eppley at internship@one12counseling.com