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ACKNOWLEDGEMENTS
By checking this box, you understand this program will expect a 10-15 hour a week commitment for at least 4 months, even if this exceeds your academic requirements.
By checking this box you are confirming your understanding that, if selected, you will be required to attend mandatory student trainings prior to starting your internship.
By checking this box, you are stating that the information on this application is true and correct..
First Name
Last Name
Address
Cell Phone
Home Phone (If Applicable)
E-Mail
Name of College/University
Address/Campus Location
Field or Practicum Advisor/Liaison
Office Phone
Program
How many hours per quarter / semester are required for your practicum?
Which days are you available to be in internship?
Mon
Tues
Wed
Thurs
Fri
Please indicate your first choice of what treatment clinic you are interested in completing your internship in
-- Select --
Blythe
Corona
Desert Hot Springs
Indio
Lake Elsinore
Riverside
Temecula
Please indicate your second choice of populations (type of client) that you would like to gain experience working with this upcoming year
-- Select --
Blythe
Corona
Desert Hot Springs
Indio
Lake Elsinore
Riverside
Temecula
What programs are you interested in completing your internship in (Note - Specialty programs offered differ within each treatment clinic)
-- Select --
Outpatient Drug-Free Program
Drug Court/Recovery Opportunity Center
Day Reporting Center
MOMS Perinatal Program
Drinking Driver Program
Do you speak a second language
Yes
No
If Yes, What other language(s) do you speak?
Can you read in your second language?
Yes
No
Can you write in your second language?
Yes
No
What is your motivation for seeking an internship with this agency?
In terms of your career - where do you see yourself in 5 years
What Population (such as ages and/or diagnoses) are you interested in gaining experience with this year
What diversity factors will you bring into this agency?
Tell us about your experience (or a family member's experience) with substance abuse services
Please provide any additional information or comments
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Demographics
Age:
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30-39
40-49
50-59
60-69
70-79
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Chinese (Mandarin and Cantonese)
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Other
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Gender identity:
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