APPLICATION FOR SANTA CLARA COUNTY MENTAL HEALTH DEPARTMENT STUDENT INTERN PROGRAM ACADEMIC YEAR

Applicants must submit the following additional information: Deadline: February 20th, 2015 (Mail to: Intern

Letter of Interest Coordinator, 1075 E. Santa Clara St. 2nd _{Floor, San} Current resume San Jose, CA 95116

Two letters of recommendation (1 academic and 1 non-academic professional) Fall Semester Field Evaluation for MSW Students

I am interested in receiving a stipend: Yes  No  I am willing to be placed in a volunteer/non-stipend position: Yes  No  I will be receiving a stipend from my college/university program (eg. SJSU- MHIP): Yes  No 

Type of Field Placement and Location seeking for Academic Year 2015-16

___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Expected Hours per Week for Field Placement for the Academic Year 2015-16________________________________ Please type or print legibly.

First Name Middle Initial Last Name(s) Current Address City State Zip Permanent Address City State Zip E-Mail Address: Home Fax:

Home Phone Number: Best Phone Number to contact you:

Current (15-16) Field Placement/Internship: Name of Agency and Location:

Previous Internships:

Agency and Supervisor Dates of internship Populations served Brief description of

Job responsibilities

Cultural Competencies (your experience and training): ______________________________________________________________ _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________ Language Skills and Proficiency (Other than English): Please rate proficiency on a scale of 1 (low) to 5 (high). You may be required to pass a proficiency test. 1: Elementary proficiency, simple conversation; 2: Limited working proficiency, casual conversation; Full-time student in a MSW or MFT graduate program or PhD/PsyD candidate program: Yes No Institution: ____________________________________ Degree and Date Expected: _______________________ Current standing: __1st _{Year __ 2}nd _{Year __ 3}rd _{Year Other ____________________________________}

Field of Study: Social Work MFT  Psychology Other _______________________ Undergraduate degree held: ____________________________ Date Conferred: _______________________________ Institution: _________________________________________________________________________________________ Cumulative Undergraduate GPA: ____________________

Advanced degree held: __________________________________ Date Conferred: ______________________________ Institution: ________________________________________________________________________________________ Academic Performance:

Supplemental Questions

Briefly respond to the three questions listed below (200 words or less for each question). 1. What influenced your decision to pursue a career in community public mental health? (i.e. lived related experience or mental health related experience)

2. Our populations in Santa Clara County come from various cultures, ethnicities, sexual orientations, all ages, different levels of physical abilities and religions. Discuss your knowledge and experience with at risk, underserved and/ or special populations and how would you ensure that each client you serve receives culturally competent services which meet the needs of their unique background?

I understand that, if I accept the Student Intern WET stipend, the expectation is that I gain employment in the California public mental health system for a minimum of one year after graduation.

YesNo

I understand that if I was previously awarded this stipend for one full year in another placement or if I receive another type of stipend or payment from a different funding source, I will not be eligible to receive this Student Intern WET stipend. YesNo

I hereby give consent to the Student Intern Program Coordinator or appointed representative to contact current and previous internship agencies/organizations and supervisors.

YesNo

I certify that the answers I have given in my completed application are true and correct to the best of my knowledge, and that I have not knowingly withheld any facts or circumstances. I understand that all responses are subject to verification and any incorrect information will result in my application being disqualified.

Signature: _____________________________________________________________ Date: ________________

Submit Completed Application Packet to:

Alexis Horozan, LMFT

Alexis.Horozan@hhs.sccgov.org

Student Intern Program and Career Pathways Coordinator Santa Clara County Mental Health Department

Learning Partnership Division

1075 E. Santa Clara St., 2nd _Floor

San Jose, CA. 95116