Name *

First Name

Last Name

Phone *

(###)

###

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Available Days *

Red Rock Counseling is based on a private practice model, giving graduate student interns 2 consecutive days in an office. What days can you be available to see clients? 

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Nights and Weekends *

Are you available to see clients in the evenings and weekends? 

Yes

No

Phone *

(###)

###

####

Contact *

May we contact your previous supervisor for a reference?

Yes

No

Phone *

(###)

###

####

Contact *

May we contact your previous supervisor for a reference?

Yes

No

I certify that my answers are true and complete to the best of my knowledge. If this application leads to performing my internship with Red Rock Counseling, I understand that false or misleading information in my application or interview may result in my release. I have reviewed the requirements of graduate student intern therapists and agree to those requirements. *

Yes

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY