Application for Internship

Education and Training

Coursework

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Completed Coursework(Required)
Please list all completed coursework for your graduate counseling program:
Completed Course Title
Completed Course Title
Completed Course Title
 
Current Coursework(Required)
Please list all in process coursework for your graduate counseling program:
Current Course TItle
Current Course TItle
Current Course TItle
 
Expected Coursework(Required)
Please list courses to be completed during your first rotation with One:12:
Expected Course Title
Expected Course Title
Expected Course Title
 

Training, Certifications & Earned Degrees

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Trainings and/or Certifications
Please list any additional training or certifications:
Training or Certification
Date
Conference or Presenter
 
Earned Degrees(Required)
Please list information for earned degrees (undergraduate and graduate):
Degree Earned
Educational Institution
Date Received
 

Supervision Experience

Additional Supervision Experience

If you have yet to receive supervision, you may skip the remainder of this section. To add additional lines, please click the plus sign to the right of the line.
Please list the information regarding your experience of supervision below:
Name of Supervisor
Supervisor's Credentials
Supervisor's Therapeutic Model
Duration
# of Hours
 

References

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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

Have you participated in didactic counseling (here defined as 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

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What days and/or times of day are you not available to see clients?(Required)
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