Alliance For Children Internship Application Form

Alliance For Children Internship Application
Name: *

First Name Last Name
Birth Date: *

Month Day Year
Social Security Number: *
000-00-0000
Phone Number: *

Area Code Phone Number
E-mail Address: *
example@example.com
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Resume: *
Picture (headshot with white background): *
Please use a headshot wit a white background
Driver's License/Passport: *
Education Completed: *

High School College Graduate School
Language(s): *
Type of Internship Interest: *

EDUCATIONAL INTERNSHIP: Internship associated with a student currently seeking a degree at a college or university, to include independent study, courses and department field placements; standardly over one or two semesters. EXPERIENTAL INTERNSHIP: Internships associated with someone who would like professional growth likened to an educational internship, but not associated with a class or degree requirement; 3 month internships available (with possibility of extensions). LICENSURE INTERNSHIP: Internships associated with someone seeking specific licensure hours).
PROGRAM OF INTEREST *

FAMILY ADVOCATE PROGRAM: Specially trained team of Family Advocates help navigate children and their protective family members through the overwhelming process of dealing with a case of child abuse from initial outcry all the way through prosecution, our Family Advocates are there to help families understand the process and successfully access needed resources in our community. Families are referred to our program through our partner agencies. Case management may include resource referrals, court preparation or accompaniment, financial assistance, coordination of emergency needs, or assistance completing Crimes Victims' Compensation applications. CLINICAL PROGRAM: Offers both individual and group counseling services to confirmed victims of child abuse and their protective family members. Our clinical counseling staff work closely with clients to determine an individualized treatment program for each child. Counseling modalities utilized include Trauma-Focused Cognitive Behavioral Therapy through individual and group counseling, and Parent-Child Interaction Therapy. MULTI-DISCIPLINARY TEAM COORDINATION PROGRAM: Partner agencies work together at Alliance For Children centers to reduce trauma to child abuse victims during an investigation and to improve their agencies’ responses to children who are often frightened and hurting. As a result of the collaboration, investigators and detectives are able to complete investigations in a more timely fashion, cases are stronger for prosecution, and children and protective caregivers are more likely to benefit from available services. CLIENT RELATIONS SPECIALIST PROGRAM: As families become involved with the investigation and our healing services, their experience from entering our family-friendly centers are critical to interventions and healing services. With an emphasis on Trauma Based Relational Interventions (TBRI), interactions with both caregivers and children are a focal point of this program.
The next portion is if you are currently enrolled in school:
College / University:
Department/Degree:
Does your internship require your field supervisor to have a specific degree and/or licensure? *

Yes No Unsure
If yes, please list degree requirement and/or licensure requirement:
Total Number of Hours Needed per Semester:
Length of Internship (if an educational internship):

Split Semesters (2 semesters) Block Semester (1 semester)
Terms:

Fall 2020 Semester Spring 2021 Semester Summer 2021 Semester Fall 2021 Semester Spring 2022 Semester
Start Date:

Month Day Year
Date
Completion Date:

Month Day Year
Date
Licensure Supervisor/ Field Liaison's Name:

First Name Last Name
Licensure Supervisor/ Field Liaison's Phone Number:

Area Code Phone Number
Licensure Supervisor/ Field Liaison's Email:
example@example.com
Internship Availability: Please note your schedule availability in the table above. **Center hours are available Monday - Friday, 8:30 AM - 5:00 PM., with some variations between centers. Evening hours are available for interns in the Clinical Department. This allows an understanding of interns general availability.
Availability:

Monday morning Monday afternoon Tuesday morning Tuesday afternoon Wednesday morning Wednesday afternoon Thursday morning Thursday afternoon Friday morning Friday afternoon Evenings (CLINICAL ONLY)

Location Preferred:

Arlington

Fort Worth

Northeast (Hurst)

Northwest (Lakeside)

First

Second

Third

Fourth

Please describe your interest in interning with Alliance For Children: *
Are you currently or have you ever received services through Alliance For Children? *

Yes No
If yes, please explain
References

Please list two (2) references that are familiar with your work life.
I authorize Alliance For Children to contact my personal references listed and understand that Alliance For Children will not be held liable for the release of this information. *

Yes No
Reference 1
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Email address:
Relationship: *
Years Known:
Reference 2
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Email address
Years Known:
Relationship: *
Emergency Contact
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Email
example@example.com
Relationship: *
Background Check Release
I grant permission to Alliance For Children to initiate, via the Department of Family and Protective Services' online self-service system, a Child Abuse/Neglect Central Registry and a Texas Department of Public Service Criminal history check as well as any subsequent checks so long as I am active with the agency. I attest that the information I provide online will be correct and that providing false information is a violation of the Texas Penal Code Section 37.10 and agree to update Alliance For Children with any changes to the information above. I am a prospective intern and concent to release information regarding criminal or abuse history to Alliance For Children. I agree to update Alliance For Children with any changes to the information above.I consent to release information regarding criminal or abuse history to Alliance For Children. I ACKNOWLEDGE I HAVE READ THE ABOVE AND HAVE PROVIDED MY SIGNATURE BELOW.
Have you ever been arrested or charged with a criminal violation of law?

Yes No
Have you been involved in a child abuse investigation?

Yes No
Have you used or sold illegal drugs within the past 5 years?

Yes No
If "yes" to the above questions, please explain:
Signature
Date

Month Day Year
Date
ALLIANCE FOR CHILDREN STAFF ONLY---------------------------
DECLINED

MDT-CP at Capacity FAP at Capacity Applicant Does Not Qualify (Background/Reference Check) Better Suited for Alternate Placement
APPROVED

Family Advocate Program Multi- Disciplinary Team-Coordination Program Clinical Program
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