Practicum Application PERSONAL INFORMATION Name Name First First Last Last Phone Email Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PROGRAM INFORMATION Are you looking for a practicum placement or external supervision? External SupervisionFull Practicum Placement School Program * Practicum Start Date * Practicum Length (months) * Required Total Hours for Practicum * Required Direct Client Contact Hours * Additional Information: Preferred Supervisor * Kayleen EdwardsJennifer LaneAny THERAPEUTIC STYLE/PREFERENCES Please describe your philosophy/beliefs when it comes to therapy, and how you wish to conduct yourself as a therapist: Check off any areas of interest or specialties * Addiction ADHD Adoption Alzheimer’s Anxiety Mood Disorders Personality Disorders Autism/ASD Behavioural Issues Career Counselling Chronic Illness/Pain Interpersonal Issues Disabilities Life Transitions Marital and Premarital Sexuality Gender Identity Issues Coming out Social Anxiety Polyamory Sex Therapy Obesity Parenting Pregnancy, Prenatal, Postpartum Racial/Cultural Identity School Issues Self-Esteem Depression Domestic Violence Eating Disorders Grief Infidelity Sexual Abuse Spirituality Sports Performance Trauma and PTSD Traumatic Brain Injury OtherOther OtherOther OtherOther Therapeutic Modality Preferences/Experience * ACT Adlerian ABA Art Therapy Attachment-Based Biofeedback Brainspotting CBT Cognitive Processing Compassion Focused DBT EMDR Emotion Focused Integrative Internal Family Systems Interpersonal Jungian Mindfulness-Based Motivational Interviewing Music Therapy Narrative Neurofeedback Person-Centered Play Therapy Prolonged Exposure Therapy Psychoanalytic Existential Experiential Therapy Family Systems Gestalt Gottman Method Humanistic Hypnotherapy Psychodynamic Reality Therapy Relational Solution-Focused Brief Therapy Somatic Strengths-Based Transpersonal Trauma Focused What types of sessions are you willing/able to do? Phone Video In Person (Hamilton) Walk & Talk (Hamilton) Walk & Talk (Other Location) List other locations. Age Demographics * <12 Years Old 12-15 Years Old 16+ 18+ Older Adults Elderly Session Types * Individuals Couples Poly Relationships Family Group Therapy Do you speak any languages besides English? * Any Special Demographics You’d like to Work with, or have experience with? (faith-based, LGBTQ+, ethnicity, etc.) Please provide any additional information you believe it would be important for us to have Preferred Supervisor * AnyJennifer LaneKayleen Edwards RESUME AND COVER LETTER Please upload your resume here * Drop a file here or click to upload Choose File Maximum file size: 516MB Please upload your cover letter here (optional) Drop a file here or click to upload Choose File Maximum file size: 516MB Submit If you are human, leave this field blank. Δ Share this: Click to share on X (Opens in new window) X Click to share on Facebook (Opens in new window) Facebook Like this:Like Loading...
