INTERNSHIP PROGRAM

Center for Creative Growth

Clinical Training Program for Interns and Trainees

Application

Please answer all questions as completely as possible. Use additional pages as needed. All information is treated as confidential material. In addition, please submit a cover letter and resume.

Date of application

SECTION I. PERSONAL DATA

Full Name

Present Address

Home Phone

Work Phone

Cell Phone

E-Mail Address

Date you are available to begin an internship with us

SECTION II. ACADEMIC BACKGROUND

A. List all colleges and graduate schools attended, the dates attended, the degree(s) completed, and the major field of study at each institute.

________________________________________________________________________

B. Registered interns: Please answer the following:

Indicate number of supervised in-session hours you have obtained to date:

What license are you working towards?

When do you plan to take your licensing exam?

What is your registered intern number?

When did you receive your intern number?

C. Graduate Students: Please answer the following:

Indicate number of hours of study completed

(indicate quarter or semester hours):

At what school:

For what degree:

When do you expect to complete the degree?

Major field:

What license are you working towards?

Indicate number of supervised in-session hours you have obtained to date:

SECTION III. PSYCHOTHERAPY AND TRAINING BACKGROUND

A. List all certificates you hold (hypnotherapy, chemical dependency, etc. the institutes that awarded them, and the dates you received them):

________________________________________________________________________

B. We do not expect you at this point in your career to necessarily have had any, or extensive, experience with any of the following therapy modalities or approaches. We are interested, however, in knowing more about what modalities you’ve been exposed to or trained in. Please respond to the following questions with a checkmark for YES when appropriate:

Have you had training or experience in:

¨ Gestalt therapy

¨ Psychodrama

¨ Family therapy _____

¨ Hypnotherapy _____

¨ Focusing ______

¨ Bioenergetics _____

¨ Other body therapies _____

(Which ones?) _______________ ______________________

¨ Couples therapy _____

¨ Hakomi _____

¨ Sandtray therapy _____

¨ Art therapy _____

¨ Inner Child/Age Regression work ______

¨ Guided Visualization or Guided Meditation _____

¨ Redecision _______

¨ 12-Step Recovery _______

¨ Others

In responding to sections IV and V, please type your responses on separate pieces of paper.

SECTION IV. PROFESSIONAL INTERESTS AND GOALS (please answer fully):

A. With reference to your proposed training at the Center for Creative Growth, please indicate why you want to train at our Center, how you heard of us, and what you wish to gain out of training with us.

B. Please provide an autobiographical description of the formation and evolution of your professional identity as a therapist.

C. What is your vision of yourself as a therapist?

SECTION V. PROFESSIONAL EXPERIENCE AND ORIENTATION:

A. Please indicate how many actual “in session” therapy hours you have had in the following categories: (1) individuals, (2) couples, (3) children,(4) families, and (5) groups.

B. List where you have done your traineeship(s) and internship(s), what type of setting each was (agency, private practice, etc.), the client population served, the dates you worked at each site, and who your supervisors were (or are).

C. Please include phone numbers of all clinical supervisors, so that we may contact them. If you do not have any previous clinical supervisors, please include names and phone numbers of two academic references and one business/professional reference.

D. Please describe each of your traineeship(s) and/or internship(s) in terms of their value or significance for you and your satisfaction or dissatisfaction with the quality of training you received.

E. In terms of your therapy experience with individuals, couples, children, families, and groups: In which area(s) do you feel most capable or comfortable? In which area(s) do you feel less capable or comfortable? If you have no direct therapy experience, please answer this question to the best of your ability based on your experience with role-plays, school training, or your interests.

F. What do you experience as your greatest difficulties as a therapist? (Particular issues, types of clients, types of feelings or interactions?) If no direct client experience yet, what do you imagine or foresee as difficulties for you as a therapist?

G. Please describe your own orientation to therapy and your beliefs about what creates healing and growth for clients. Which orientation or theoretical school do you consider yourself to be a member of or most in theoretical alignment with?

H. Please share your familiarity with, if any, and perspective on 12-step programs, and their relationship to therapy.

I. Please tell us about your familiarity, if any, with John Bradshaw and his work. Tell us which, if any, of his workshops you attended, books you read, PBS television series you watched.

J. What do you see as the role of spirituality in the practice of psychotherapy?

K. Is there anything else that you think would be helpful or important for us to know about you or that you would like to share with us?

Thank you for completing this application.

Please mail to:

Center for Creative Growth

Training Program Application

1221 Marin Avenue

Berkeley, CA 94706

or e-mail to: jasons@creativegrowth.com

www.creativegrowth.com