Training Inquiry - Mind Wellness Center

1. Training Position

Select the position you are applying for.

I am applying for the following training position *

Ph.D. / Psy.D. Externship Doctoral-level extern — typically 8-16 hours/week including supervision — for students currently enrolled in an APA-accredited doctoral program in psychology. Master's-Level Internship Master's-level intern — typically 15-20 hours/week including supervision — for students currently enrolled in a CACREP-accredited or comparable counseling or social work program.

Training year applied for *

Academic year *

Preferred location(s) * (check all that apply)

Ithaca, NY Capital Region, NY Burlington, VT Telehealth / remote Open to any

2. Personal Information

First name *

Last name *

Email address *

Phone number *

- -

Pronouns (optional)

Mailing address *

City / State / ZIP *

3. Academic Program

University / Program name *

Degree *

Expected graduation date *

Current year in program *

Program director / DCT name *

Program director / DCT email *

Program address *

Program accreditation status * (check one)

APA-accredited (doctoral) CACREP-accredited (master's) CSWE-accredited (social work) Accreditation in progress Other / Not accredited

4. Practicum & Training History

List your previous or current practicum / training placements. Fill at least one row.

Site / Organization

Supervisor name

Dates

Population / Focus

Total direct service hours (approximate) *

Total supervision hours (approximate) *

6. Availability

Training start date *

Training end date *

Hours available per week *

Hours required by program *

Days available * (check all that apply)

Monday Tuesday Wednesday Thursday Friday Flexible

Availability for telehealth *

Yes — available for telehealth In-person only preferred No preference

7. Supervision Needs & Training Goals

Supervision format required by your program * (check all that apply)

Individual supervision (1:1) Group supervision Live supervision Video review Case consultation

Primary training goals for this placement *

What do you hope to contribute to the MindWell team? *

8. References

Please provide two supervisors or faculty who can speak to your clinical and academic work.

Reference 1

Name *

Title / Role *

Institution / Organization *

Email *

Phone (optional)

Reference 2

Name *

Title / Role *

Institution / Organization *

Email *

Phone (optional)

Reference 3 (optional)

Name

Title / Role

Institution / Organization

Phone

9. Application Checklist

Please confirm the following documents are included with your application.

Completed application form Cover letter Two reference contacts (listed above) Current CV or resume Unofficial graduate transcripts Program verification / enrollment letter (if required)

Please email your CV / resume, cover letter, and supporting documents to info@mindwellcenter.com after submitting this application.

10. Certification

I certify that all information provided in this application is accurate and complete. * I understand that misrepresentation may result in disqualification from consideration or dismissal from a training position.

Signature * (typed full name)

Date *

✓

Application Submitted!

Thank you for your interest in a training position at MindWell Psychology. We have received your application and will be in touch within 1-2 weeks regarding next steps. Please email your CV / resume and supporting documents to info@mindwellcenter.com.

Inquire About Training Opportunities

MindWell Psychology