Internship Sign Up – Dallas Area Rape Crisis Center

Personal Information

What type of internship are you interested in?*

Clinical/Therapeutic
Non-Clinical

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Phone Number (Work)

Date of birth: (MM/DD/YY)*

Employer (or if full-time student, university)*

Are you bilingual? If so, please specify what other languages you are fluent in*

Email*

Internship Interview Questionnaire:

1. What led you to choose this program, and what do you hope to contribute to it?*

2. Please list any background working with sexual assault survivors and/or any related volunteer experience.*

3. What do you anticipate would be the most difficult part of this program for you?*

4. How do you feel about working with/assisting people who are of different race, religion, belief or lifestyle than yours?*

5. Have you or anyone you know been a victim of sexual assault? If yes, how long ago and what have you done to work through it?*

6. We prohibit the use of mind-altering drugs and alcohol while on call. Can you agree to abide by this policy? (Yes or No) If no, please explain.*

7. Are you currently on probation or parole or completing community service hours? (Yes or No) If yes, please explain.*

8. Have you been arrested, charged or convicted of a crime(s), or have any charges currently pending against you? (Yes or No) If yes, please explain.*

9. Are you willing to complete paperwork, keep track of services, and document all client contact? (Yes or No) If no, please explain.*

10. Client confidentiality is a top priority at DARCC. Do you foresee having a problem in this area? (Yes or No) If yes, please explain.*

References

Please list two people other than relatives and friends:

1. Name and Phone Number:*

2. Name and Phone Number:*

Please list other/past related volunteer experience (include program, your position, your supervisor, and their phone number if available):*

Internship Application

Personal Information

Internship Interview Questionnaire:

References

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