CHICAGO AREA CHRISTIAN TRAINING CONSORTIUM
INTERNSHIP IN PROFESSIONAL PSYCHOLOGY
APPLICATION FACE SHEET
(Must be included as a part of Application Supplemental Materials)
NAME: DATE:
ADDRESS:
PHONE:
EMAIL:
GRADUATE INSTITUTION:
(including your program’s training model)
DISSERTATION TOPIC/EXPECTED STATUS OF DISSERTATION (as of 8/1):
EXPECTED GRADUATION DATE:
PRESENTATIONS/PUBLICATIONS (at professional conferences):
Please complete in full
Please indicate (with an “X”, do not rank) which CACTC sites you wish to be considered for internship placement:
____ Lawndale Christian Health Center ___ Lydia Home Association
____ Cornerstone Cnlg Center of Chicago ___ Outreach Community Ministries