* indicates required field
* First Name
* Last Name
* Email Address
* Confirm Email Address
* Type of Internship
Please complete the fields only for your type of internship.
Name of University
If you selected "Other," what is your degree type?
Expected Internship/Practicum Start Date (MM/DD/YYYY)
Anticipated Internship/Practicum End Date (MM/DD/YYYY)
Does your program require:
Video/audio taping of sessions
Types of Therapies
Individual TherapyFamily TherapyGroup Therapy
Are you currently in supervison?
If yes, how many hours have you obtained?
* Please attach a PDF of your resume to this application.