Southwest Human Development : Creating a Positive Future for Young Children

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Infant/Family Clinical Practice
Application For Admission

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

First Name	Last Name


Address

,

Phone Number (Home)
( ) -

Phone Number (Work)
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Phone Number (Cell)
( ) -

Email Address


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

Institution (name and location)


Years Attended


Degree


Major Subject



Institution (name and location)


Years Attended


Degree


Major Subject



Institution (name and location)


Years 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


Discipline


In what year are you enrolled in your current coursework
1 2 3 4 or more

Expected date of completion



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

Employer


Address

,

Phone Number


Duties



Employer


Address

,

Phone Number


Duties



Employer


Address

,

Phone Number


Duties



Employer


Address

,

Phone Number


Duties




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


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


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



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


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



What do you suppose it is about your life that explains your interest in the field of infant mental health?



Professional References
Please provide three professional references.

Name


Address

,

Relationship


Phone Number
( ) -


Name


Address

,

Relationship


Phone Number
( ) -


Name


Address

,

Relationship


Phone Number
( ) -

Please mail us the following documents: • A current copy of your curriculum vitae or resume. • A letter on your employer’s letterhead from your supervisor or CEO stating that they are in support of your attending the training institute and that you have their permission to utilize agency clients for your clinical experience. • 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: Tina Basoco Harris Infant and Early Childhood Mental Health Training Institute Southwest Human Development 2850 N. 24th Street Phoenix, AZ 85008

Southwest Human Development Arizona Institute for Early Childhood Development

2850 North 24th Street Phoenix, AZ 85008 Phone: 602-266-5976 Fax: 602-274-8952