Name:
Address:
Phone:
School
Degree Program:
Email:
If not in school, are you working towards CAC (Ceritified Addictions Counselor) certification?	Yes No
Desired Start Date:
Length Internship Desired:
Will you require supervision by a Centennial Peaks staff member?	Yes No
If yes, what credentials are required of the CPH supervisor?
How many hours of supervision are required during the internship?
Does your school have an outline of intership expectations, goals, and objectives?	Yes No
Is there anything else you would like to tell us about yourself? (Prior experience, skills, etc.)?