Application Form

Applicant Information

Full Name

Phone

Graduate Program & Training

Graduate School/University

Degree Program

What year are you currently in your graduate program?

What dates does your program require your placement to begin and end?

Placement Requirements

I have verified with my graduate program that a fully virtual/telehealth practicum or internship placement is permitted and meets my program’s requirements.

I have verified with my graduate program that supervision by a clinician who has been independently licensed for three years meets my program’s requirements for practicum or internship supervision.

How many total hours and direct clinical hours does your program require?

What supervision requirements does your graduate program have?

Please include the required frequency and type of supervision and any supervisor credential requirements.