Harris Infant/Family Clinical Practice Application

The Harris Infant and Early Childhood Mental Health Training Institute (Infant/Family Clinical Practice)

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
Name*
First Last
Address*
Street Address City State ZIP Code
Phone (Home)
Phone (Work)
Phone (Cell)
Email*
Education History
List all colleges and graduate institutions that you have attended or are attending and each degree earned or being pursued:*
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
In what year are you enrolled in your current coursework
- 1
- 2
- 3
- 4
- or more
Expected Date of Completion
Date Format: MM slash DD slash YYYY
Employment History
List employment over past 3 years, including job responsibilities (start with most recent job):
Employer*
Employer Address*
Street Address City State ZIP Code
Employer Phone*
Duties*
Employer
Employer Address
Street Address City State ZIP Code
Employer Phone
Duties
1. Participation in the Harris training program requires that you be in a position to provide mental health services to children birth to 3 years old by the second semester of Year 1 of the program. Describe how you would meet this requirement:*
2. How will your career goals be supported by the Harris Infant & Early Childhood Mental Health Training Institute? Please provide an in-depth response. (min. 300 words)*
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 5 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. Please provide an in-depth response. (min. 300 words)*
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? Please elaborate in your response. (min. 300 words)*
Professional References
Please obtain and provide two professional reference letters (not friends or neighbors) and list their contact information below. You can either mail the letters or have them mailed to the Harris contact at the end of this application.
Reference #1 Name*
First Last
Reference #1 Address
Street Address City State ZIP Code
Relationship to Reference #1*
Reference #1 Phone Number*
Reference #2 Name*
First Last
Reference #2 Address
Street Address City State ZIP Code
Relationship to Reference #2*
Reference #2 Phone Number*
Important Terms and Conditions. Please Read.
Please mail us copies of the following documents: A current copy of your curriculum vitae or resume. Two professional reference letters or note that they will be sent to the Harris office. 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 adviser 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 for your highest level of education completed and any additional diplomas or certificates that may be pertinent to this program. WHEN YOU SEND US YOUR COPIES, PLEASE DO NOT FOLD THEM. Please mail these documents to: Peggy Baxter, 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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Institution Name and Location	Year Attended	Degree	Major Subject

The Harris Infant and Early Childhood Mental Health Training Institute (Infant/Family Clinical Practice)

Contact Information

Education History

Employment History

Professional References

Important Terms and Conditions. Please Read.

Helping Arizona Children & Families