• Student Information

  • School Information

  • Please list the school where you are currently enrolled in.
  • Please list the degree and/or credential you are currently pursuing.
  • Name, phone number, and e-mail address of faculty liaison at your school.
  • Internship Details

  • Please list the when you will need to start your internship.
  • Please list the when you will need to end your internship.
  • Days of the week you are available for an internship.
  • Please list the number of clinical hours per week required for your internship.
  • Please list the number of hours of clinical supervision you are required to receive per week.
  • Degree and/or credentials your clinical supervisor must hold.
  • Any other requirements or stipulations for your internship