Fieldwork MatchingForm

Fall 2015 - Spring 2016

Applicant Information

Name: / Date: / Desired Fieldwork Term: / -
Phone number: / Email address:
Check the one that best applies: / MSW Intern – 1st year
MSW Intern – 2nd year
MSW Intern – 3rd year
MFT Trainee – 2nd year
Other: __ / Have you completed a fieldwork placement/ traineeship with Seneca in the past?: / Yes, this will be my placement.
(EXAMPLE: Yes, this will be my 2nd placement.)
Location of previous placement/s: ______
No, this will be my 1st placement.
University & City: / Expected Graduation Date:

Seneca Family of Agencies Policies

Please initial each box below to indicate that you understand and intend to comply with each of the following Seneca policies for graduate level interns and trainees.
Seneca asks that all graduate interns/trainees commit to their field placement for at least 9 to 10 months.
All staff and graduate level interns/trainees must complete a two week training (Monday through Friday 9:30am to 5:30pm) prior to placement in a program. Most interns/trainees complete this training during the summer prior to placement. If you anticipate scheduling conflicts please note them here:
To maintain a safe environment for staff, interns/ trainees, and clients all staff and interns/trainees are trained on a de-escalation model that may include restraint and seclusion.

Applicant Interests

Placement Setting (Check all that apply. Please note that not all of these settings may be available in your area.):
Adoption and Permanency / School-based
Mental Health / Community-Based
Which populations are you interested in working with? (Rank your choices: 1= 1st Choice)
Elementary School / Teens / Youth on Probation
Adolescents / Children & Families / Youth in Foster Care
Geographic location: In which locations are you interested in working? (Rank your choices: 1=1st Choice)
Northern California / Southern California / Central California
Alameda County
Contra Costa County
San Francisco County
Santa Clara County
Sonoma County / Anaheim Hills, CA
Tustin, CA
Redlands, CA / Salinas, CA
San Luis Obispo, CA
Do you have a car available? (Some sites are not accessible by public transport and we provide transportation for clients in most programs):
Yes I have a car, am insured and able to transport clients.
Yes I have a car, am insured but not able to transport clients.
No I do not have access to a car, but am willing to drive a vehicle if provided.
How did you hear about Seneca Family of Agencies?
Please expand on your personal and professional goals that you hope to achieve while interning or training at Seneca Family of Agencies:
Additional comments:

Thank you for your interest in Fieldwork at Seneca Family of Agencies

Please attach this form to your CV and resume when submitting your online application no later than March 31st, 2015.
Please note that it may take up to five business days to hear back from us regarding the status of your application.
If you have any further questions please contact our Fieldwork Manager, Jennifer Nguyen
at Seneca Institute of Advanced Practice (510) 542-1307.