Date Internship must be Secured
MM
DD
YYYY
Date Your Internship Begins
MM
DD
YYYY
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
MM
DD
YYYY
School you are Attending, Expected Graduation Date and Degree at Graduation
What are the direct and indirect hours requirements set forth by your graduate program?
Please provide specific hours totals you are required to obtain throughout your practicum and internship. (ie. direct service, relational, supervision, group, indirect service, etc).
Program Accreditation
CACREP
COAMFTE
None
Which Languages are you Fluent in?
How did you hear about Therapy Associates of Tacoma?
Do you have any experience as a client in therapy?
Yes
No
Have you ever been convicted of any criminal activity or hand any ethics violations?
Yes
No
If yes, please explain the circumstances. This will not necessarily prevent you from an invitation to our program.
Should you be selected for placement at TAT, are you willing to comply with any background check requirements?
Yes
No
TAT believes a good self-care practice and support network are essential to facilitating and sustaining quality clinical work. Please describe your self-care practices, including what support system you have.
In your graduate program and/or personal therapy, please describe what you have learned about yourself in regards to how you relate to yourself and others?
TAT is a private practice therapy internship that aims to prepare and cultivate post-graduate private practice clinicians. Additionally, we are dedicated to providing a stable experience for our clientele. Please describe your level of interest in private practice and what are your post-graduate goals?
At TAT we value social justice and are committed to understanding how social systems impact our mental health. How have you been personally impacted by systemic oppression and/or privilege? How might these experiences inform your clinical practice?
Transference and counter-transference are common features of therapy. Please describe how transference and counter-transference can influence therapy, both in beneficial and harmful ways.
Please describe your current limitations, vulnerabilities, and/or biases that may impact your clinical work and/or ability to sit with specific client populations? How will you address these limitations when they arise?
Commitment and Availability: TAT has a number of practicum and internship positions available. Scheduling availability is a key factor in the extension of an invitation into our Clinical Training Program. As best as you can at this time, please indicate the days you are expected to be available for direct and indirect internship hours. Both in-person and telehealth hours will be required.
Please describe the hours you anticipate being available on each day indicated above:
Are you available to commit to seeing 15 clients per week for the duration of your contract?
Yes
No
TAT asks for a weekly time commitment of between 20-25 hours, including direct client hours, individual and group supervision, and administrative work. Can you make this committment?
Yes
No
Attestation: By typing your name below, you attest that you understand and agree that submitting this application does not automatically register you as an intern with TAT. Additionally, by submitting this form you attest that the information you have provided is true and is submitted voluntarily.
*
Date of Applicaiton
*
MM
DD
YYYY