The Family Institute of Neve Yerushalayim

P. O. Box 43016 - Jerusalem91430

Tel: (02) 654-4600 Fax: (02) 654-4601

E-mail:

Yisrael Levitz, Ph.D

Director

APPLICATION FORM

2012-2013

Please mark which program you are applying for:

Clinical Internship / Externship / Domestic Violence / Adolescence Unit / Pinat HaYeled

Application Fee: NIS 100

Deadline: May 15th, 2012

Name: ______

Family MiddleFirst

ID (Teudat Zehut #) or Passport #: ______

Address:______

Home Phone: ______Work number: ______

Cell Phone:______Email: ______

Education:

Highest Degree Achieved:______Field of Study: ______

Institution:______Date Completed: ______

Please indicate below those courses of study that you have completed and/or attended that are relevant to your preparation as an intern/student at the Family Institute of Neve Yerushalayim:

Please verify degrees and courses by sending an official transcript to the Family Institute of Neve Yerushalayim, Attention of Dr. Yisrael Levitz, Director.

INSTITUTION / COUNTRY / DEGREE / FROM -TO / FIELD OF STUDY
LANGUAGE COMPETENCY
Language / Speak Fluently / Moderately / Poorly / Comprehend
English
Hebrew
Russian
French
Yiddish
Other

After reading the descriptive material pertaining to the requirements of the Clinical Internship Program at the Family Institute, please respond to the following questions:

  1. Do you have at least one year of supervised clinical experience in either an internship/practicum of similar practice framework? Yes______No______
  2. Where did you receive this training? ______

Name of Facility

  1. How many years of supervised clinical experience do you have? ______
  1. Can you briefly describe the nature of your clinical experience to this point, including a brief description of your caseload, client population, and types of issues worked with?

______

______

______

  1. Have you completed the following prerequisite courses or their equivalent on a Graduate level?

Name of
Course / Course/ Equivalent / Institution Attended / Instructor/
Grade / Date Completed
Psychosocial Pathology
Human Development
Family Systems
  1. You may apply for credit if you have already completed 400* level courses or their equivalent on a graduate level with a minimum B grade. Please indicate which of these course requirements you have fulfilled, and the relevant information pertaining to each course. These will need to be substantiated by official transcripts.

FI 400.6
Clinical Intervention I:
Family Therapy
FI 400.8
Clinical Intervention II: Couple’s Therapy

*Please note: 400 level courses will be considered for equivalency credit at the discretion of the faculty.

  1. Please provide the name, address, and telephone number of your last Supervisor and attach their letter of recommendation or last evaluation.

______

______

  1. Clinical Internship Statement

The caseload responsibilities for full time interns at the Family Institute require an average of 6 client contact hours per week at the Family Institute of Neve Yerushalayim. In addition, interns will receive live/group supervision, Case Conferences, individual supervision, and didactic Professional Development seminars totaling approximately 12 hours per week**. Moderate level of Hebrew language fluency is necessary in ordre to complete 350 hours within 2 year.

Are you prepared to make this time commitment? Yes______No______

Comments:______

**At least one afternoon/evening of client contact is necessary in order to be able to see families in the clinic.

Applications must be received by our office no later than May 15th, 2012. In order to process your application, and arrange an interview with the faculty committee, please be sure to attach the following:

Application Fee of NIS 100 payable to Neve Yerushalayim

Letter or recommendation or evaluation from previous clinical supervisor.

Resume

Transcripts of Graduate level courses

Recent passport photograph

______

Signature Date