Clinical Internship Application Personal InformationName* First Last Pronouns*She/ her/ hersHe/ him/ hisThey/ them/ theirsOtherPrefer not to answerAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Date of birth: (MM/DD/YY)* Date Format: MM slash DD slash YYYY Other Required InformationUniversity Counseling Graduate Program:*DARCC requires interns to have liability insurance through their university and/or personal liability insurance. Is this something you can agree to?*YesNoDARCC also requires interns to commit to at least 6 months of internship for at least 16 hours a week, with mandatory weekly meetings on Tuesdays 11am-1pm. Our interns are also required to do internships in-person at 2801 Swiss Ave, Dallas, TX 75204, with both virtual and in-person counseling appointments. Can you make this commitment? If you have any concerns, please specify.*YesNoWhen are you available to start?* Date Format: MM slash DD slash YYYY I am seeking an internship for the... Fall Semester Spring Semester Summer Semester Select all that apply.Have you ever received services from DARCC?*YesNoUnsureWhat counseling license are you working towards (LPC, LMFT, LCSW, Clinical Psychologist)?* LPC LMFT LCSW Clinical Psychologist Are you bilingual? If so, please specify what other languages you are fluent in.*