Infantfamilypractice
 
 

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
Education History

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




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

(Example mm/yy)
Employment History

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

Professional References

Please provide three professional references



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