LPC Internship Application Form

LPC Intern Application

Fill the form below accurately for internship with Elizabeth Davis, MA, LPC-S.
Name: *

First Name Last Name
Birth Date

Month Day Year
Phone Number: *

Area Code Phone Number
E-mail Address:
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How were you referred to Elizabeth Davis, MA, LPC-S or Embrace New Life, LLC? *

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US Citizen:
Upload Resume:
Upload Copy of Graduate Transcript:
What is your LPC-Intern number and what is your anticipated completion date for hours?
Job Skills & Training
Describe your previous work history and professional skills: *
Military or Government Contractor Experience: *
What experience do you have with Podcasting, VLogging, Adobe, or other multimedia? Are you interested in using technology in the delivery of psychotherapy?
References

Please list two (2) references, one from a professor and the other a spouse, friend or pastor that can attest to your ethical standards.
Professor
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Years Known: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Spouse / Friend / Pastor
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Years Known: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Should be Empty:

LPC Intern Application