Please Submit Your Application and Payment Via

Internship Program Application

(18 and older)

Thank you for your interest in MGH Aspire. There are 2 ways to complete the application: you may download the application forms and enter your responses electronicallyor you may print the forms and enter handwritten responses.

☐ / Internship Program Application (18 and older)
☐ / Applicant Photo (may be electronic)
☐ / $75 non-refundable application fee for NEW Aspire applicants (instructions below)
☐ / Most recent Neuropsychological or Psychological Evaluation
☐ / Most recent copy of your resume (if you have one)
☐ / Releases of Information (as applicable)
☐ / Medical Record Number (MRN)
Applicantsmust registerwith the Massachusetts General Hospital Registration & Referral Center. Please call the Center at 781-960-1203 to register and obtain a Medical Record Number (MRN).

Please Submit Your Application and Payment Via:

Email /
Phone / 781-860-1900
Fax / 781-860-1920
Mail / MGH Aspire
1 Maguire Road
Lexington, Massachusetts 02421
Aspire accepts checks payable toMGH Aspire and sent to the address above or a credit card over the phone at 781.860.1900.
You will receive a confirmation email within 5 business days of Aspire receiving your application.
Applications are accepted on a rolling basis. Candidates will be scheduled for an intake session
at our main office in Lexington upon receipt of the complete application packet.
Please contact us at 781-860-1900 or email us at if you have any questions.
A $750 non-refundable program deposit is due upon program acceptance. Program tuition must be paid in full prior to the start of group. Aspire does not offer refunds.
Copies of background check procedures, healthcare and discipline policies are available upon request.

Financial assistance is awarded based on financial need and fund availability.

The financial aid application can be downloaded from our website.

Thank you for applying to the MGH Aspire program!

Demographic Information
First Name: / Last Name:
Home Address:
City: / State: / Zip Code:
DOB: / Pronoun: / MGH MRN:
Home Phone: / Cell Phone:
Email: / Primary Language:
Race: / Ethnicity (e.g., Hispanic): / Gender:
Do you live:
☐ At home with parent(s). If so, do you live with: ☐ Both Parents ☐ Mother ☐ Father
☐ In a dormitory/university housing.
If you checked this box, do you live:☐ Alone ☐ With a roommate
☐ In your own apartment.
If you checked this box, do you live:
☐ Alone ☐ With a roommate ☐ In supported housing
Please list the name(s) of your parent/guardian(s):
Parent/Guardian Name 1:
Parent/Guardian Name 2:
Do you give Aspire staff permission to speak with your parents about this application,
☐Yes ☐No
If no, please explain your requested restrictions:
If yes, please provide contact information for your parent/guardian(s) below:
Parent/Guardian 1 Name: / Phone: / Email:
Parent/Guardian 2 Name: / Phone: / Email:
Emergency Contact Name:
Relationship: / Phone: / Email:
How did you hear about us? ☐ Internet ☐ School
☐ Agency (AANE, etc.) ☐ Conference: ☐Other provider:
Are you legally eligible to work in the U.S.? Please check one: ☐Yes ☐ No
If you are not a U.S. citizen, please explain any restrictions on your eligibility for employment:
Transportation Information
Please check your expected transportation:
☐ Participant will drive ☐ Public Transportation ☐Family member
☐ Other, please specify (The RIDE, e.g.):
Personal Information
If you have received a format diagnosis, for example Asperger’s Syndrome, ASD, PDD-NOS, NLD, ADHD, or other? If yes, please list:
What do you consider to be your greatest strengths?
What are your personal interests and hobbies?
Why are you interested in the career program?
Please list 2 goals that you would like to achieve in this programs
1.
2.
Career/Interests Inventory
Please review the general list of careers and job skills below. Place a check mark next to those that are of interest to you. If you think you might be interested in a career or job related skill but need more information, highlight or circle the skill.
Career Areas / Job Related Skills
☐ / Accounting/Finance / ☐ / Accounting
☐ / Art / ☐ / Analyze Data
☐ / Automotive / ☐ / Answer phones and great customer service
☐ / Business / ☐ / Create and run database reports
☐ / Communications/Marketing / ☐ / Customer Service
☐ / Computers (Coding or Fixing) / ☐ / Data entry
☐ / Development/Fundraising / ☐ / Drive a van and deliver products
☐ / Engineering / ☐ / Familiarity with programming languages (e.g., SQL, Java, CII, ASP, .NET, XML)
☐ / Healthcare (administrative) / ☐ / Lift and move up to 50 lbs.
☐ / History / ☐ / Maintain warehouse inventory
☐ / Information Systems (IS) / ☐ / Perform basic bookkeeping
☐ / Legal / ☐ / Research
☐ / Museums / ☐ / Working knowledge of Microsoft Word, Access, PowerPoint and Excel
☐ / Office Administration / ☐ / Working knowledge of Social Medial systems
☐ / Science
This Resume page can be completed, OR you can attach a copy of your most recent resume instead.
Resume Form
Education
History / Name of School / Location
(City, State) / Dates Attended
(start date – end date) / Major and Degree
(as applicable)
High School
College
Other
Please list any scholastic honors you have received:
Please list any technical licenses or certificates you have obtained:
Employment or Volunteer History
Most Recent Organization: / Location:
Start Date: / End Date:
Description of duties:
Organization: / Location:
Start Date: / End Date:
Description of duties:
Organization: / Location:
Start Date: / End Date:
Description of duties:
Collateral Contacts
Former Supervisor (if applicable)
Name: / Role:
Agency: / Email:
Town: / State: / Zip Code:
Phone: / Fax:
Professional who interacts with applicant outside of school or work (e.g. Psychologist, Psychiatrist, or Social Worker)
Name: / Role:
Agency: / Email:
Town: / State: / Zip Code:
Phone: / Fax:
How long have you been seeing this professional?:
How frequently do you see this provider?:
Additional Reference
Name: / Role:
Agency: / Email:
Town: / State: / Zip Code:
Phone: / Fax:
This Supplemental Information page should be completed by a personal reference, for example a parent/guardian, therapist, etc. Please answer the following questions about the applicant.
Supplemental Information
Applicant name:
What are the applicant’s greatest strengths and skills?
What are the applicant’s challenges? Is the applicant self-aware of these challenges?:
Please list 2 goals that you would like the applicant to achieve during the program:
1.
2.
Please list any special considerations Aspire should be aware of (sensory issues, personal habits, triggers, best calming strategies, etc.):
Please share any other information or concerns that you think would be helpful for Aspire to know:
Reference Information
What is your relationship to the applicant?☐Mother☐Father☐Other
What is your name?
Application Signatures
I hereby make an applicationto attend Aspire Programs.
I have filled out all the information to the best of my knowledge.
Applicant Signature (if applicant is 18 years or older) / Date:
Legal Guardian Signature (if applicable) / Date:
Legal Guardian Signature (if applicable) / Date:

Person responsible for payment and billing:

Signature (if not provided above)
Name/Relationship: / Date:

A note on insurance:

Please be aware that Aspire offers multidisciplinary interventions that do not fit standard medical procedure codes; therefore, our services are not reimbursable by medical insurers.

☐ Yes - I plan to submit a financial aid application.

☐ Yes - add me to the Aspire Wire (electronic newsletter) at the following email address:
☐ Yes - add me to the Lurie Center Research electronic newsletter at the following email address:

“Unencrypted” Email preference (optional):

The Partners standard is to send email securely. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to Aspire communications.

Signature / Email:
Signature / Email:

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1 Maguire Road, Lexington, MA 02421 | Tel 781-860-1900 | Fax 781-860-1920 |