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Intern Application Form

  
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Please select one




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Anticipated Start (Fall 2014, Summer 2014)
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First Name
M.I.
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Last Name
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Address
Address 2
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City
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State

Example: NY

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ZIP Code

Example: 12345

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Daytime Phone

Example: 123-123-1234

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Evening Phone

Example: 123-123-1234

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Email
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School Name
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School Address
School Address 2
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City
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State

Example: NY

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ZIP Code

Example: 12345

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School Liason to Field Site Name

(Please include credentials and title)

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Phone

Example: 123-123-1234

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Do you have any prior clinical training placements?

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Do you have any mental health work experience?

State

Example: IL

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GPA

0.00

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Are you fluent in another language?
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Please list graduate level courses completed to date

Are these areas of past experience and/or areas of interest?

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Outpatient Adult Therapy


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Child & adolescent outpatient therapy


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Psychosocial rehabilitation


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Transitional Living Program/Residential program


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Vocational & supportive employment


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Vocational & supportive employment


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Case management


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School Mental Health


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Partial Hospitalization Program


Additional Comments
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Please explain your interest in obtaining your training in community mental health
Alexian Brothers
Medical Center

800 Biesterfield Road
Elk Grove Village, IL
60007
847-437-5500
Alexian
Rehabilitation Hospital

935 Beisner Road
Elk Grove Village, IL
60007
847-640-5600
St. Alexius
Medical Center

1555 Barrington Road
Hoffman Estates, IL
60169
847-843-2000
Alexian Brothers
Behavioral Health
Hospital

1650 Moon Lake Boulevard
Hoffman Estates, IL
60169
800-432-5005
Alexian Brothers
Women & Children's
Hospital

1555 Barrington Road
Hoffman Estates, IL
60169
847-843-2000
  • Primary Care
  • Addison
  • Barrington
  • Bartlett
  • Bloomingdale
  • Elgin
  • Elk Grove Village
  • Hanover Park
  • Itasca
  • Mt. Prospect
  • Palatine
  • Palatine/Rolling Meadows
  • Poplar Creek
  • Schaumburg
  • Streamwood
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