Internship Application | One:12 Counseling Charlotte, NC, Ballantyne Area

Application for Internship

First Name(Required)

Last Name(Required)

Street Address(Required)

Address Line 2

City(Required)

State / Province / Region(Required)

Zip / Postal Code(Required)

Country(Required)

Home Phone

Cell Phone(Required)

Email(Required)

Education and Training

Name of Graduate Degree Pursuing:(Required)

Name of Educational Institution:(Required)

Expected Date of Graduation:(Required)

Coursework

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Completed Coursework(Required)

Please list all completed coursework for your graduate counseling program:

Completed Course Title

Current Coursework(Required)

Please list all in process coursework for your graduate counseling program:

Current Course TItle

Expected Coursework(Required)

Please list courses to be completed during your first rotation with One:12:

Expected Course Title

Training, Certifications & Earned Degrees

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Trainings and/or Certifications

Please list any additional training or certifications:

Training or Certification

Date

Conference or Presenter

Earned Degrees(Required)

Please list information for earned degrees (undergraduate and graduate):

Degree Earned

Educational Institution

Date Received

Supervision Experience

Please describe what you are looking for in your supervision at One:12:

Additional Supervision Experience

If you have yet to receive supervision, you may skip the remainder of this section. To add additional lines, please click the plus sign to the right of the line.

Please list the information regarding your experience of supervision below:

Name of Supervisor

Supervisor's Credentials

Supervisor's Therapeutic Model

Duration

# of Hours

Please describe two examples of something you gained through supervision.

Could anything have improved your previous supervisory experience?

Please describe two examples of constructive feedback that you received during your supervision:

How did you experience this feedback?

References

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Please provide at least three (3) references, including email address and phone number, who can speak to who you are as a mental health counselor intern or marriage and family therapist intern. Please include at least one graduate program professor and, if applicable, at least one supervisor as references. A character reference may be included as one of the three.(Required)

Name

Phone Number

Reference Type

Didactic Counseling

Have you participated in didactic counseling (here defined as personal counseling for the purposes of counselor formation and learning) as a part of your graduate program?(Required)

Yes

If so, how has your experience of didactic counseling influenced you as a therapist in training?

Theoretical Orientation

Please describe the theoretical approaches you hope to employ during your time at One:12:(Required)

Why have you chosen these models?(Required)

Faith Integration

How would you integrate faith into your practice of counseling?(Required)

Communication Style

What is your Myers Briggs Type?

What is your Enneagram number?

How would you describe your communication style?(Required)

Services Capacity

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What days and/or times of day are you not available to see clients?(Required)

Day

Time

What types of client populations are you interested in engaging?(Required)

Counselors at One:12 have a specialty area that they develop with us. Do you have a specialty area and if so, please share more about it?(Required)

One:12 also has couples and children that often reach out for counseling. Because of the need, we also offer additional training and support for either of these populations. Are you interested in either of these areas and if so, please speak more to it?(Required)

Are there types of clients with whom you are not willing to work? If yes, please explain:(Required)

Resume

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Please upload your resume.

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If you have further questions, you are welcome to contact our Clinical Director, Jessee Eppley at [email protected]