PC EP Apply

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To prevent errors or lost information, please complete this application using Google Chrome on a desktop or laptop computer. Other browsers, phones, and tablets are not supported and may break the form. If you do not receive a confirmation email within 2 business days of submitting, please contact lgreen@pmhcc.org. Personal Information[break]Last Name: *

Please fill out the Last Name field

First Name : *

Please fill out the First Name field

Cell Phone: *

Please fill out the Cell Phone field

School Email Address: *

Please fill out the School Email Address field

Personal Email Address: *

Please fill out the Personal Email Address field

Address 1: *

Please fill out the Address field

Address 2:City, State, Zip: *

Please fill out the City, State, and Zip fields

What day of the week works best with your anticipated schedule this school year? *
Please choose both if either day is acceptable.MondayFridayDo you have any food allergies we should be aware of (for the provision of lunch)?[break]

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Academic InformationSchool/University Name: *

Please enter the School or University Name

Degree you are currently pursuing: *

Please enter the degree that you are currently pursuing

BSWMSWMSSMAMSPhDPsyDOtherIf other, please specify:Field Liaison First Name: *

Please enter the Liaison First Name

Field Liaison Last Name: *

Please enter the Liaison First Lame

Field Liaison Email Address: *

Please enter the Liaison Email Address

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Practicum / Field Placement Information
If unknown or not applicable, please indicatePracticum Name:Department / ProgramPracticum Address:Agency Suite or Floor Number:Agency City, State, Zip:Field Supervisor Last Name:Field Supervisor First Name:Field Supervisor Title:Field Supervisor Email:

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Learning Needs and Professional DevelopmentWhat skills or experiences do you feel you’re currently missing that would help you feel more confident entering the behavioral health field? *