Clinical Internship Form | Compass Health

Name*

First Last

Chosen Name (If different than above)

Chosen Pronouns

School*

Phone

Email*

What is the name of the degree you are pursuing? (e.g. Master's of XX)*

Are you looking for a practicum and/or internship placement? (Check all that apply)*

Practicum
Internship
Other

What is the start date of your practicum/internship course? Please provide Month and Year*

At the time of your practicum/internship experience, how many years into your educational program will you be (e.g. 1st Year, 2nd Year, 3rd Year, etc.)?

1st Year
2nd Year
3rd or 4th Year

At the time of your practicum/internship experience, will you be enrolled in a specific program?

Generalist or Foundation
Advanced or Specialization or Concentration
Not Applicable

Are you a Washington State Workforce Development Initiative (WDI) Recipient?

Yes
No

Are you able to commit to interning at least 2 days a week/15-20 hours per week? Note – Most internship opportunities within our agency are during typical business hours on weekdays.*

Yes
No

What program(s) are you interested in? (Check all that apply)*

Adult Outpatient
Adult Intensive Outpatient
Child & Family Outpatient
Child & Family Intensive Outpatient
Crisis Response & Stabilization
Inpatient & Residential Programs

Which counties are you available to intern? (Check all that apply)*

Snohomish County
Skagit County
Island County
San Juan County
Whatcom County

Do you have any special interests? (For example: Working with adult clients; working in non-traditional settings; etc.)

Attach your resume*

Drop files here or

Max. file size: 50 MB.

Anything else you would like to let us know in determining a practicum/internship placement? Example – Do you have limitations in your availability?

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