Stillwater Family Therapy

2100 Sepulveda, Suite 30

Manhattan Beach, CA  90266

(310)378-2520

www.stillwatergroup.net

Intern Application

Date:_________________________

Name:_________________________________

Address:______________________________________________

            ________________________________________________

            ________________________________________________

Professional Phone:_______________________________________

Private Phone:_____________________________________________

Email:________________________________________________

SSN:______________________________________________________

DOB:________________________________________________________

Intern #:_________________________________________

Please attach copies of your intern number letter from the BBS, Master's degree, transcript, driver's license, and resume.

(Please use additional sheets to answer the following questions.)

1. What drew you to psychotherapy as a profession?

2. What theoretical orientation are you most familiar with today? Which would you like to do more of?

3. Do you want to be in private practice some day?

4. What networks do you belong to today? (i.e., alumni association, CAMFT local chapter, Chamber of Commerce, school alumni association, church affiliation, networking group (i.e., BNI), volunteer organizations, hobby groups). Do you have a leadership role in any of those groups?

5. How many hours per week can you devote to your practice as part of Stillwater?

6. What would be a satisfactory weekly income you would like to receive from Stillwater?

7. What hours/days of the week do you have open?

8. Can you attend weekly supervision in the mornings?

9. Who is your favorite kind of client to work with?

10. What kind of clients like you best?

Thanks so much for your interest in Stillwater Family Therapy. Please mail this application with attachments to our office and we will get back to you about possibly scheduling an interview.