Adult Internship Program Application – Page 2
Internship Program Application
Thank you for your interest in Aspire’s programs. There are 2 ways to complete the application: you may download the application forms and enter your responses electronically or you may print the forms and enter handwritten responses.
A complete application includes:
Internship Program Application (to be completed by applicant)
Applicant Photo (may be electronic)
$75 non‐refundable application fee for NEW Aspire applicants.
Most recent Neuropsychological or Psychological Evaluation
Most recent copy of your resume (if you have one)
Medical Record Number (MRN): Please see instructions below on how to get your MRN:
To apply to an Aspire program, each applicant must register with the Massachusetts General Hospital Registration and Referral Center. Please call the MGH Patient Referral and Registration Department at 781-960-1203 and register (a parent must register the applicant if applicant is under age 18) to obtain a Medical Record Number (MRN).
Please Submit Your Application Via:
Email/ Fax
781-860-1920 / Mail
MGH Aspire
1 Maguire Road
Lexington, Massachusetts 02421
You will receive a confirmation email within 5 business days of Aspire receiving your application.
Applications are accepted on a rolling basis. Candidates will be scheduled for an intake session
at our main office in Lexington upon receipt of the complete application packet.
Please contact us at 781-860-1900 or email us at if you have any questions.
A $200 non-refundable program deposit is due upon program acceptance.
Program tuition must be paid in full prior to the start of group. Aspire does not offer refunds.
Financial assistance is awarded based on financial need and fund availability.
The financial aid application can be downloaded from our website.
Thank you for applying to Aspire’s program!
Be sure to check this sheet for required attachments and submittal information.
This application should be completed by the Intern applicant.
Demographic InformationFirst Name: / Last Name:
Home Address:
City: / State: / Zip Code:
DOB: / Age: / MGH MRN:
Home Phone: / Cell Phone:
Email: / Primary Language:
Do you live:
At home with parent(s). If so, do you live with: Both Parents Mother Father
In a dormitory/university housing.
If you checked this box, do you live: Alone With a roommate
In your own apartment.
If you checked this box, do you live: Alone With a roommate In supported housing
Please list the name(s) of your parent/guardian(s):
Parent/Guardian Name 1:
Parent/Guardian Name 2:
Do you give Aspire staff permission to speak with your parents about this application, your progress in the program, billing and other pertinent items? Please check one: Yes No
If no, please explain your requested restrictions:
If yes, please provide contact information for your parent/guardian(s) below:
Parent/Guardian 1 Name: / Phone: / Email:
Parent/Guardian 2 Name: / Phone: / Email:
How did you hear about us? Internet School
Agency (AANE, etc.) Conference: Other provider:
Are you legally eligible to work in the U.S.? Please check one: Yes No
If you are not a U.S. citizen, please explain any restrictions on your eligibility for employment:
Transportation Information
Please check your expected transportation:
Intern will drive Public Transportation Family member
Other, please specify (The RIDE, e.g.):
Personal Information
Have you received a formal diagnosis, for example Asperger’s Syndrome, ASD, PDD‐NOS, NLD, ADHD, or other? If yes, please list:
What do you consider to be your greatest strengths?:
What are your personal interests and hobbies?:
Why are you interested in the internship program?:
Please list 2 goals that you would like to achieve in this program:
1.
2.
Careers/Interests Inventory
Please review the general list of careers and job skills below. Place a check mark next to those that are of interest to you. If you think you might be interested in a career or job related skill but need more information, place an X in the box.
Career Areas / Job Related Skills
Accounting/Finance / Accounting
Art / Analyze Data
Automotive / Answer phones and great customer service
Business / Create and run database reports
Communications/Marketing / Customer Service
Computers (Coding or Fixing) / Data entry
Development/Fundraising / Drive a van and deliver products
Engineering / Familiarity with programming languages (i.e. SQL, Java, C#, ASP, .NET, XML)
Healthcare (administrative) / Lift and move up to 50 lbs.
History / Maintain warehouse inventory
Information Systems (IS) / Perform basic bookkeeping
Legal / Research
Museums / Working knowledge of Microsoft Word, Access, PowerPoint and Excel
Office Administration / Working knowledge of Social Media systems
Science
This Resume page can be completed OR you can attach a copy of your most recent resume instead.
Resume FormEducation
History / Name of School / Location
(City, State) / Dates Attended
(start date – end date) / Major and Degree (if applicable)
High School
College
Other
Please list any scholastic honors you have received:
Please list any technical licenses or certificates you have obtained:
Employment or Volunteer History
Most Recent Organization: / Location:
Start Date: / End Date:
Description of duties:
Organization: / Location:
Start Date: / End Date:
Description of duties:
Organization: / Location:
Start Date: / End Date:
Description of duties:
Collateral Contacts
Former Supervisor (if applicable)
Name: / Role:
Agency: / Email:
Town: / State: / Zip Code:
Phone: / Fax:
Therapist who supports applicant outside of school or work (e.g. Psychologist, Psychiatrist, Social Worker)
Name: / Role:
Agency: / Email:
Town: / State: / Zip Code:
Phone: / Fax:
How long have you been seeing this professional?:
How frequently do you see this provider?:
Additional Reference (former teacher, guidance counselor, provider)
Name: / Role:
Agency: / Email:
Town: / State: / Zip Code:
Phone: / Fax:
This Supplemental Information page should be completed by a personal reference, for example a parent/guardian, therapist, etc. Please answer the following questions about the applicant.
Applicant name:
What are the applicant’s greatest strengths and skills?:
What are the applicant’s challenges? Is the applicant self-aware of these challenges?:
Please list 2 goals that you would like the applicant to achieve during the program:
1.
2.
Please list any special considerations Aspire should be aware of (sensory issues, personal habits, triggers, best calming strategies, etc.):
Please share any other information or concerns that you think would be helpful for Aspire to know:
Reference Information
What is your relationship to the applicant? Mother Father Other
What is your name?
Application Signatures
I hereby make an application to attend Aspire Programs.
I have filled out all of the information to the best of my knowledge.
Applicant Signature (if applicant is 18 years or older)
/ Date:
Legal Guardian Signature (if applicable)
/ Date:
Person responsible for payment and billing:
Name/Relationship:
A note on insurance: Please be aware that Aspire offers multidisciplinary interventions that do not fit standard medical procedure codes; therefore, our services are not reimbursable by medical insurers.
Yes - I plan to submit a financial aid application
Yes - add me to the Aspire Wire (electronic newsletter) at the following address:
Yes - add me to the Lurie Center Research electronic newsletter at the following address:
1 Maguire Road, Lexington, MA 02421 | Tel 781-860-1900 | Fax 781-860-1920 | www.mghaspire.org