APPLICATION FOR SANTA CLARA COUNTY MENTAL HEALTH DEPARTMENT STUDENT INTERN PROGRAM ACADEMIC YEAR

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1 Applicants must submit the following additional information: Deadline: February 20th, 2015 (Mail to: Intern Letter of Interest Coordinator, 1075 E. Santa Clara St. 2 nd Floor, San Current resume San Jose, CA Two letters of recommendation (1 academic and 1 non-academic professional) Fall Semester Field Evaluation for MSW Students I am interested in receiving a stipend: Yes No I am willing to be placed in a volunteer/non-stipend position: Yes No I will be receiving a stipend from my college/university program (eg. SJSU- MHIP): Yes No Please type or print legibly. First Name Middle Initial Last Name(s) Current Address City State Zip Permanent Address City State Zip Address: Home Fax: Home Phone Number: Best Phone Number to contact you: Type of Field Placement and Location seeking for Academic Year Expected Hours per Week for Field Placement for the Academic Year Current (15-16) Field Placement/Internship: Name of Agency and Location: Field Placement Supervisor: Phone Number: Year of Internship: 1 st year 2 nd year other: SCCMHD SIP Internship Application Form Page 1 of 5

2 Full-time student in a MSW or MFT graduate program or PhD/PsyD candidate program: Yes No Institution: Degree and Date Expected: Current standing: 1 st Year 2 nd Year 3 rd Year Other Field of Study: Social Work MFT Psychology Other Undergraduate degree held: Date Conferred: Institution: Cumulative Undergraduate GPA: Advanced degree held: Date Conferred: Institution: Academic Performance: G.P.A. of most recent academic school year completed: Semester/Year No. of units carried? At what institution? : Previous Internships: Agency and Supervisor Dates of internship Populations served Brief description of Job responsibilities Cultural Competencies (your experience and training): Language Skills and Proficiency (Other than English): Please rate proficiency on a scale of 1 (low) to 5 (high). You may be required to pass a proficiency test. 1: Elementary proficiency, simple conversation; 2: Limited working proficiency, casual conversation; 3: Professional working proficiency, more complex forms of communication; 4: Full professional proficiency, some cultural context; 5: Native or Bilingual proficiency. Language: Speak Written Language: Speak Written Language: Speak Written SCCMHD SIP Internship Application Form Page 2 of 5

3 STATEMENT OF PURPOSE: Please write a brief, (350 words or less) essay, describing your personal and professional goals (other than obtaining your license). Include your interest, skills, and experience working with culturally and linguistically diverse, underserved populations. Include your efforts to help consumers within an organizational context. For students applying for a clinical internship stipend, comment on your reasons for selecting this location as a possible placement and the clinical skills you hope to develop. (For more space, attach additional sheets of paper or use backside). SCCMHD SIP Internship Application Form Page 3 of 5

4 Supplemental Questions Briefly respond to the three questions listed below (200 words or less for each question). 1. What influenced your decision to pursue a career in community public mental health? (i.e. lived related experience or mental health related experience) 2. Our populations in Santa Clara County come from various cultures, ethnicities, sexual orientations, all ages, different levels of physical abilities and religions. Discuss your knowledge and experience with at risk, underserved and/ or special populations and how would you ensure that each client you serve receives culturally competent services which meet the needs of their unique background? 3. As the mental health system is in the process of being transformed to a wellness and recovery focused system, based on your knowledge, what are the challenges faced by the system to meet consumer needs? SCCMHD SIP Internship Application Form Page 4 of 5

5 I understand that, if I accept the Student Intern WET stipend, the expectation is that I gain employment in the California public mental health system for a minimum of one year after graduation. I understand that if I was previously awarded this stipend for one full year in another placement or if I receive another type of stipend or payment from a different funding source, I will not be eligible to receive this Student Intern WET stipend. I hereby give consent to the Student Intern Program Coordinator or appointed representative to contact current and previous internship agencies/organizations and supervisors. I certify that the answers I have given in my completed application are true and correct to the best of my knowledge, and that I have not knowingly withheld any facts or circumstances. I understand that all responses are subject to verification and any incorrect information will result in my application being disqualified. Signature: Date: Submit Completed Application Packet to: Alexis Horozan, LMFT Student Intern Program and Career Pathways Coordinator Santa Clara County Mental Health Department Learning Partnership Division 1075 E. Santa Clara St., 2 nd Floor San Jose, CA Tel: (408) Fax: (408) SCCMHD SIP Internship Application Form Page 5 of 5

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