Apply Now for the Infant/Family Clinical Practice Program

2850 N. 24th Street

Phoenix, AZ 85008

(602) 266-5976

The Harris Infant and Early Childhood Mental Health Training Institute

Application

All fields are required. If you have no answer, put N/A. Please be aware that this application does not have a save option.

Contact Information

First name

Last name

Address

City

State

Zip

Phone Number (Home)

Phone Number (Work)

Phone Number (Cell)

Email Address

Education History

List all colleges and graduate institutions that you have attended and each degree earned:

Institution Name and Location

Year Attended

Degree

Major Subject

Institution Name and Location

Year Attended

Degree

Major Subject

Institution Name and Location

Year Attended

Degree

Major Subject

If you are currently in a degree program, please provide the following information:

Institution in which you are enrolled

Discipline

Degree for which you are enrolled

Expected Date of Completion (Example mm/yy)

Employment History

List employment over past 3 years, including job responsibilities (start with most recent job):

Employer

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone Number

Duties

Employer

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone Number

Duties

Employer

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone Number

Duties

Employer

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone Number

Duties

1. Participation in the Harris training program requires that you be in a position to provide mental health services to children birth to three years old by the second semester of Year One of the program. Describe how you would meet this requirement:

2. How do you see your career goals being supported by the Harris Infant & Early Childhood Mental Health Training Institute?

3. What is your formal training in child development & infant/early childhood mental health? If you have none, please say none.

4. Describe all professional work with children under the age of five years and indicate setting(s) in which you did this work. If you have no such work experience, please say none.

5. Share your beliefs about the role of parents and/or caregivers in the therapeutic process.

6. What do you suppose it is about you and your life experiences that has contributed to your interest in the field of infant mental health?

Professional References

Please provide three professional references

Reference Name

Reference Address

Reference City

Reference State

Reference Zip

Relationship

Reference Phone Number

Reference Name #2

Reference Address #2

Reference City #2

Reference State #2

Reference Zip #2

Relationship #2

Reference Phone Number #2

Reference Name #3

Reference Address #3

Reference City #3

Reference State #3

Reference Zip #3

Relationship #3

Reference Phone Number #3

Terms and Conditions

Please mail us copies of the following documents:

A current copy of your curriculum vitae or resume.
If you are attending class as a part of your employment a letter on your employer’s letterhead from your supervisor or CEO stating that they support your attending the training institute must be included.
If you are a student, a letter on university/college letterhead from your advisor stating that you are in good standing in your program and that you have a practicum experience that will provide clients birth to three years of age.
Copy of your diploma(s).

WHEN YOU SEND US YOUR COPIES, PLEASE DO NOT FOLD THEM.

Please mail these documents to:
Devin Dale
Harris Infant and Early Childhood Mental Health Training Institute
Southwest Human Development
2850 N. 24th Street
Phoenix, AZ 85008

By checking here I understand and agree to the following: The Harris training program makes a clear distinction between consultation, as provided by Harris faculty, and supervision, as provided by my place of employment, academic program, or other contracted arrangement. Clinical and other professional material discussed with Harris faculty is for the purpose of reflection and my professional development but is not meant to direct the course of individual cases. The responsibility for cases and professional decisions through the course of my contact with clients rests with my supervisor and myself.

By checking here I certify that all statements provided in this application are true.

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Infant/Family Clinical Practice

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The Harris Infant and Early Childhood Mental Health Training Institute

Application

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