AOD

Step 1 : Alcohol or Drug Abuse Program - Application
Please fill out the contents below.


Provide accurate and up-to-date personal contact information
Provide accurate and up-to-date personal contact information
Provide accurate and up-to-date personal contact information
Provide accurate and up-to-date personal contact information
Provide accurate and up-to-date personal contact information
Provide accurate and up-to-date personal contact information
Provide all requested College information.
What is the address of the school/campus you attend?
Provide the name and contact information for the university representative we would contact regarding your placement
Provide the Office Phone contact information for the university representative we would contact regarding your placement
Indicate your discipline and the year of schooling you will be starting in the fall
How many hours per quarter / semester are required for your practicum
Indicate which days you will be available for placement in this agency.
Please indicate your first and second choice of what treatment clinic you are interested in completing your internship in?
Please indicate your first and second choice of populations (type of client) that you would like to gain experience working with this upcoming year.
What programs are you interested in completing your internship in (Note: Specialty programs offered differ within each treatment clinic)
Indicate if you speak a second language, including American Sign Language. Specify which additional language(s) you speak and if you read and write in that language
Indicate if you speak a second language, including American Sign Language. Specify which additional language(s) you speak and if you read and write in that language
Indicate if you speak a second language, including American Sign Language. Specify which additional language(s) you speak and if you read and write in that language
Indicate if you speak a second language, including American Sign Language. Specify which additional language(s) you speak and if you read and write in that language
Indicate if you speak a second language, including American Sign Language. Specify which additional language(s) you speak and if you read and write in that language
Use the designated areas to answer the questions. Do not attach additional pages.
Use the designated areas to answer the questions. Do not attach additional pages.
Use the designated areas to answer the questions. Do not attach additional pages.
Use the designated areas to answer the questions. Do not attach additional pages.
We recognize that it is still vulnerable for people to talk about a substance use treatment history. This information will not be shared with perspective field sites without your permission. We want you to know that RUHSBH is committed to the full integration of people with consumer or family member experience into our programs and workforce. We see this experience as an asset.
Please provide any additional information or comments
Field level help.