Appalachian State University Psychology Clinic

Appalachian State University Psychology Clinic

Undergraduate Internship Application

Please complete the following items. The information you provide will be used in evaluating your application for training and for general identification purposes.

Name:______Date of Birth: ______

Date of Application:______

Semester you would like to work at the ASU Psychology Clinic:______

Current Major: ______

MailingE-mail

Address:Address: ______

Telephone - Home:Other:

Education:

College/UniversityMajor/ DegreeGPAMajor GPA

Related Work Experience:

Company/OrganizationMajor DutiesInclusive Dates

Please attach a copy of your Vitae/Resume

Appalachian State University Psychology Clinic

Undergraduate Internship Application

Please describe why you are interested in an Internship at the ASU Psychology Clinic.

What are your major training interests?

What are your professional goals?

Do you have any special skills that would be useful at the ASU Psychology Clinic?

Reference (a professor who knows you well, who will compete the attached reference form):

NameAddressE-mailPhone

1.

Return your completed application to:Jacqueline Hersh, Ph.D.

(email is preferred)Director, ASU Psychology Clinic

Appalachian State University

ASU Psychology Clinic

251b Industrial Park Drive

Boone, NC 28608

Fax: 828-262-2974

ASU Psychology Clinic

Reference Form

______has applied for an undergraduate internship at the ASU Psychology Clinic and has listed you as a person who is well-positioned to comment on his/her qualifications and personal attributes that would make him/her a competitive candidate. Please complete this form and return it to the address below. Thank you for your candid evaluation of this applicant.

Name of Reference:______

How long have you known this applicant?______

In what capacity have you known this applicant?______

Please rate the applicant on the following:

1. Interpersonal abilities:LowMediumHighVery High

1. Emotional Maturity:LowMediumHighVery High

1. Professionalism:LowMediumHighVery High

1. Initiative:LowMediumHighVery High

1. Reliability:LowMediumHighVery High

In the space below, please comment on the applicant’s skills and attributes that would make him/her a good candidate for an internship in a clinical profession. Also, please address his/her promise for graduate work in a clinical profession. If you prefer, you may attach a letter that addresses these issues.

______

Signature of Reference Date

Return your reference form to:Jacqueline Hersh, Ph.D.

(email is preferred)Director, ASU Psychology Clinic

Appalachian State University

ASU Psychology Clinic

251b Industrial Park Drive

Boone, NC 28608

Fax: 828-262-2974

1