MENTAL HEALTH SERVICES PROGRAM - RECREATION THERAPY
Student Placement APPLICATION
Type or Print the following information and attach a resume:
Name:_______________________________________ Date:____________________
Current Address:________________________________________________________
Home phone:________________________ Cell phone:_________________________
Email Address:__________________________________________________________
Permanent Address:______________________________________________________
Anticipated Placement start date:____________________________________
Please indicate Mental Health service area preferences for placement (1-3):
____
____
____
____
____
____
Acute Care (Dartmouth - Nova Scotia Hospital)
Acute Care (Halifax – Abbie J. Lane)
Recovery and Integration (Dartmouth)
Forensics
Seniors Mental Health
Community Mental Health
References (Min. of two):
Name:_____________________________________ Phone:______________________
Email:__________________________ Relationship to Applicant:___________________
Name:_____________________________________ Phone:______________________
Email:__________________________ Relationship to Applicant:___________________
Name:_____________________________________ Phone:______________________
Email:__________________________ Relationship to Applicant:___________________
**Please Note:
*Please include references from volunteer and/or work experience. Family/friends are
not appropriate references.
*Current instructor of program will be contacted and must be included in above
references.
Please ensure the following are included before submitting application:
 Completed Application Form
 Resume
 Please list names of three individual references (ie. Volunteer, educational,
personal, etc.)
Mental Health Services Student Placement Application
AGREEMENT
Please read carefully and sign below.
The information in this application is accurate and complete to the best of my
knowledge. I understand that falsifying or omitting information on this application
may disqualify me or subject me to dismissal
____________________________________
Signature
_____________________________
Date
Return this application to:
Mail: Robert Baird, BSc, BRec, CTRS
Recreation Therapist, Professional Practice Leader
Rm 9516, Abbie J. Lane Bldg
5909 Veterans’ Memorial Lane
Halifax, NS B3H 2E2
Fax: (902) 473-2454
If you have any questions, contact Mental Health Services Recreation Therapy
Professional Practice Leader:
Robert Baird, BSc, BRec, CTRS
Phone: (902) 473-4346
Email: Robert.baird@cdha.nshealth.ca