Mental Health & Substance Use Internships in Eastern NC

Full Name

Full Address

Email

Home Phone

Cell Phone

NCDL #

Place of Birth

General Information

College / University currently attending

Major

Internship Preference

Position

Location

Population of Interest

Adult Mental Health

Adult Substance Use

Youth Mental Health

Youth Substance Use

Internship Level

Undergraduate

Graduate

When does your internship start?

When does your internship end?

How many internship hours do you need to complete?

College/University Contact Information

Name

Title

If yes, Please indicate names

THE STATE OF NORTH CAROLINA REQUIRES THAT A CRIMINAL RECORD BACKGROUND CHECK AND HEALTH CARE REGISTRY CHECK BE CONDUCTED ON ALL PROSPECTIVE INTERNS PR

Have you ever been convicted of child abuse or neglect or any other criminal offense, or forfeited a bond?

Yes

No

(NOTE: A CONVICTION WILL NOT NECESSARILY EXCLUDE YOU FROM CONSIDERATION FOR INTERNSHIP. FACTORS SUCH AS AGE AT THE TIMES OF OFFENSE, REHABILITATION EF

If yes, Please explain

Describe what qualities you feel you would add to our organization?

What professional growth goals will be addressed with this internship?

Please read the following statements carefully and submit: I certify that the information I have provided accurately represents my background and that

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Employment

Internships

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