ࡱ> ceb L=bjbj -Maa &&TJJJv,J:FFFF!nkp: : : : : : :,<M?lL:]!!L:FF:FFF::66n97!7 ::0:7??8n9n9L:L::?& :   Name:  FORMTEXT       Phone Number:  FORMTEXT       Date of Application:  FORMTEXT       Email Address:  FORMTEXT       Address:  FORMTEXT       Academic Information Name of University:  FORMTEXT       Area of Specialization:  FORMCHECKBOX Clinical  FORMCHECKBOX Counseling Degree Type:  FORMCHECKBOX Ph.D.  FORMCHECKBOX Psy.D.  FORMCHECKBOX Other,  FORMTEXT       Years of graduate school completed:  FORMTEXT       Clinical Training Director: Name:  FORMTEXT       Email:  FORMTEXT       Address:  FORMTEXT       Phone Number: FORMTEXT       Professional licenses or certifications:  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please describe:  FORMTEXT       Clinical Experience Intervention Courses Taken?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please list courses:  FORMTEXT       Intervention experience (e.g., individual or group therapy):  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please describe:  FORMTEXT       Assessment Courses Taken?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please list courses:  FORMTEXT       Assessments administered/scored/ or interpreted?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please describe:  FORMTEXT       Practical Experience Please describe any other practical experience that you have had (ex.: "volunteered on a crisis hot line"):  FORMTEXT       Additional Information What are   "$&024@F`bdxz|ӧӗzezZeLe?h(5CJOJQJaJjhP.UmHnHujthP.U(jh hP.5CJOJQJUaJh hP.5CJOJQJaJh%,q5CJOJQJaJhP.hP.5CJOJQJaJ-jh 5CJOJQJUaJmHnHu(jh 5CJOJQJUaJ"jh 5CJOJQJUaJhP.5CJOJQJaJh 5CJOJQJaJ2 l n d f h    hd`hgd dgd_k hd`hgd%,q  & Fdgd_k dgd d&dPgdWHEm$ dgd m$ " $ . 0 B D F Z \ ^ h ٲqZMM8(jh 5CJOJQJUaJh 5CJOJQJaJ-jhP.5CJOJQJUaJmHnHu(j\hP.5CJOJQJUaJ"jhP.5CJOJQJUaJh%,q5CJOJQJaJhP.5CJOJQJaJhP.hP.5CJOJQJaJ-jh 5CJOJQJUaJmHnHu"jh 5CJOJQJUaJ(jh 5CJOJQJUaJh j l n   : < > P R sdXJ;h%,qh CJOJQJaJjh_khP.Uh CJOJQJaJh_kh_kCJ OJQJaJ jh_khP.UmHnHujDh_khP.U%jh%,qhP.CJOJQJUaJh%,qhP.CJOJQJaJhP.5CJOJQJaJh_khP.5CJOJQJaJh.h 5CJOJQJaJh 5CJOJQJaJ"jh 5CJOJQJUaJR n p r  * , . < > R T V ` b d f h {o`Qh hP.CJOJQJaJh_kh_kCJ OJQJaJ h CJ OJQJaJ jh_khP.UmHnHujh_khP.Ujh_khP.Ujh_khP.Ujh_khP.Uh CJOJQJaJ%jh%,qhP.CJOJQJUaJj,h_khP.Uh%,qhP.CJOJQJaJ      $ & : < > H ݯsdQCQ2 jh_khXMUmHnHujh_khXMU%jh hXMCJOJQJUaJh_khP.CJOJQJaJh h CJOJQJaJh_khXMCJOJQJaJh h_kCJOJQJaJh hXMCJOJQJaJh_kh_kCJ OJQJaJ jh_khP.UmHnHujph_khP.Uh hP.CJOJQJaJ%jh hP.CJOJQJUaJH J L P ^ ` t v x ݾݰsbSEjDh_khXMUh_kh_kCJOJQJaJ jh_khXMUmHnHujh_khXMUh6ph_kCJ OJQJaJ h hXMCJOJQJaJ jh_kh UmHnHujXh_kh U%jh h CJOJQJUaJh CJOJQJaJh h CJOJQJaJ%jh hXMCJOJQJUaJ P    HJ hd^hgd>X  & Fdgd_kd&dPgdWHE  & FdgdXM dgd_k dgd hhd^h`hgd d^gd_k d`gd       p r ͊͘Ͳ{h{Rh+jh_khXMCJOJQJUaJ%jh_khXMCJOJQJUaJh_khXMCJOJQJaJj.h_khXMUjh_khXMUh CJ OJQJaJ h_kh_kCJOJQJaJh CJOJQJaJh hXMCJOJQJaJ%jh hXMCJOJQJUaJ jh_khXMUmHnHu FHJLŵ|mZmLZmZm>Zmj h_kh jNUj h_kh jNU%jh6ph jNCJOJQJUaJh6ph jNCJOJQJaJh6pCJOJQJaJh>Xh>X5CJOJQJaJhXM5CJOJQJaJh_khXM5CJOJQJaJh%,qhXM5CJ OJQJaJ h_khXMCJOJQJaJ%jh_khXMCJOJQJUaJ0jh_khXMCJOJQJUaJmHnHuJ<>v  p24 hd^hgd*g  & Fdgd*gd&dPgdWHE dgd6p d`gd6p dgd_k hd`hgd6p*,.8:<>LǴǦzgzYgzgzKgzj h_khEUjv h_khEU%jh6phECJOJQJUaJh6phECJOJQJaJh6pCJOJQJaJ jh_kh jNUmHnHuj h_kh jNU%jh6ph jNCJOJQJUaJh6ph jNCJOJQJaJh_kh_kCJOJQJaJh6ph6pCJOJQJaJh jNCJOJQJaJNPdfhrt  ޯޣkUFh6ph6pCJOJQJaJ+jH h_khXMCJOJQJUaJ+j h_khXMCJOJQJUaJ%jh_khXMCJOJQJUaJh_khXMCJOJQJaJh6pCJOJQJaJ0jh_khECJOJQJUaJmHnHu+j^ h_khECJOJQJUaJ%jh_khECJOJQJUaJh_khECJOJQJaJHJ^`bln~  (*,0246hj~ޯޣwhRޯ+jh_kh jNCJOJQJUaJh6ph6pCJOJQJaJ+j h_kh jNCJOJQJUaJ+j2 h_kh jNCJOJQJUaJh6pCJOJQJaJ0jh_kh jNCJOJQJUaJmHnHu+j h_kh jNCJOJQJUaJ%jh_kh jNCJOJQJUaJh_kh jNCJOJQJaJ464ĵscSDBDUh*ghECJOJQJaJh_khE5CJOJQJaJh%,qhE5CJ OJQJaJ h*ghXM5CJOJQJaJ jh_kh jNUmHnHujh_kh jNU%jh*gh jNCJOJQJUaJh*gh jNCJOJQJaJh*g5CJOJQJaJh_kh jN5CJOJQJaJh%,qh jN5CJ OJQJaJ h_khECJOJQJaJ^4055555566D7F77788F9H9::;$d&dP^a$gdWHEd&dPgdWHE hd^hgd*g  & Fdgd*gyour goals for externship?  FORMTEXT       Have you ever worked with an inpatient psychiatric population?  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