GW Postgraduate Fellow Application Instructions
Thank you for your interest in working with the George Washington University’s Counseling
Center for your postgraduate fellowship. In order to be considered for the fellowship, please be
sure you have included all of the following materials:
☐
Curriculum Vitae (CV)
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Cover Letter
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Completed Application (pages 2-6 below) – Complete this application electronically, save
to your personal computer and attach the file in an email.
Letter from Academic Advisor – This letter, on official letterhead, should verify that you
will graduate in good standing on or before 7/31/14.
☐
Your application is not considered complete in the absence of any one of the above
components.
In one email, please send all of the above materials to Mike Kohn, Human Resources Client
Partner, at mkohn@gwu.edu. You will receive an email confirming receipt of your application,
but given the volume of applications, you will not be able to get an update on your status
following application submittal.
Should you have any technical issues with the application, please do not hesitate to get in touch
with Mike at the above email address.
Thank you again for your interest in working with the University Counseling Center at the
George Washington University!
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GW Postgraduate Fellow Application
Please fill in all fields electronically as prompted below. This file can be saved to your personal computer
and attached in an email when completed.
CONTACT INFORMATION
First Name
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Last Name
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Street Address
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Apartment
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City
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State
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Country
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Zip Code
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PERSONAL INFORMATION
Citizenship Status Choose from list.
Country of
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Citizenship
Other Citizenship
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Veteran?
Yes or No.
GENERAL
Preferred Name or Nickname
Do you have materials under another name?
If yes, specify other names used
Language(s) other than English (including American
Sign Language) in which you are fluent enough to
conduct therapy
CERTIFICATIONS
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Home Phone
Work Phone
Cell Phone
Preferred Phone
Primary Email
Secondary Email
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Choose from list.
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Do you hold a Visa?
Visa Type
Yes or No.
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Visa Number
City of Visa Issue
Visa Current and Valid?
Visa Permits Work?
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Yes or No.
Yes or No.
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Yes or No.
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Enter the name of Jurisdiction 1.
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Enter the name of License 2.
Enter the name of License 3.
Enter the name of License 4.
Enter the name of Jurisdiction 2.
Enter the name of Jurisdiction 3.
Enter the name of Jurisdiction 4.
PROFESSIONAL CONDUCT
Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor,
educational or training institution, health care institution, professional association, or
licensing/certification board?
If ‘Yes,’ please elaborate: Click here to enter text.
Are there any complaints currently pending against you before any of the above bodies?
If ‘Yes,’ please elaborate: Click here to enter text.
Has there ever been a decision in a civil suit rendered against you relative to your
professional work, or is any such action pending?
If ‘Yes,’ please elaborate: Click here to enter text.
Have you ever been put on probation, suspended, terminated or asked to resign by a
graduate or internship training program, practicum site or employer?
If ‘Yes,’ please elaborate: Click here to enter text.
Have you ever been convicted of an offense against the law other than a minor offense
against the law other than a minor traffic violation?
If ‘Yes,’ please elaborate: Click here to enter text.
Have you ever been convicted of a felony?
If ‘Yes,’ please elaborate: Click here to enter text.
Will you graduate from your current graduate program on or before 7/31/14 in good
academic standing?
If ‘No,’ please elaborate: Click here to enter text.
EDUCATION – CURRENT INSTITUTION
Institution Name
Department
Program Name
College Name
Degree Seeking
GPA
Accreditation Status
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EDUCATION – PRIOR INSTITUTION
Institution Name
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Yes or No.
Yes or No.
Yes or No.
Yes or No.
Yes or No.
Yes or No.
Yes or No.
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Type
Major
Minor/Second Major
Degree Pursued
Degree Status
Degree Date
GPA
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EDUCATION – PRIOR INSTITUTION (leave blank if no additional institution to mention)
Institution Name
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Type
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Major
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Minor/Second Major
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Degree Pursued
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Degree Status
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Degree Date
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GPA
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INTERVENTION EXPERIENCE – Check the boxes to indicate if you have experience in the below areas and
be sure to highlight endorsed experiences in your CV.
Individual Therapy
Career Counseling
Adults (25-64)
☐ Adults
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College Aged Adults (18-25)
☐ Adolescents (13-17)
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Adolescents (13-17)
Family Therapy
Family Therapy
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Other Psychological Interventions
Group Counseling
Adults
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Adolescents (13-17)
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Intake Interview/Structured Interview
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Couples Therapy
Substance Abuse Interventions
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Couples Therapy
Eating Disorders
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Other Psychological Interventions
Multicultural/International Students
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Trauma Interventions
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Veterans
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Sport Psychology/Performance Enhancement
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Outreach/Consultation
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Supervision
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ADDITIONAL INFORMATION ABOUT PRACTICUM EXPERIENCE – Check the boxes to indicate if you have
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experience in the below areas and be sure to highlight endorsed experiences in your CV.
Child Guidance Clinic
☐ Partial Hospitalization/Intensive Outpatient
Community Mental Health Center
☐ Programs
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Department Clinic
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Private Practice
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Forensic/Justice Setting
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Residential/Group Home
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Inpatient Psychiatric Hospital
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Schools (K-12)
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Medical Clinic/Hospital
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Outpatient Psychiatric Clinic/Hospital
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University Counseling Center/Student Mental
Health Center
VA Medical Center
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Other practicum experience?
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ANTICIPATED EXPERIENCE
Description of
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anticipated experience
between application
date and 7/31/14.
Please highlight
experience in any
specialty or other
relevant area. Write
“N/A” if no additional
experience expected.
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Confidential EEO and AA Information
The George Washington University requests the following information to be in compliance with Federal
and local government regulations. Please note that your response is voluntary. It will be viewed by
University Human Resources only. Further, your response will have no bearing whatsoever on your
employment application.
VOLUNTARY DEMOGRAPHIC INFORMATION
Gender
Are you Hispanic or Latino? Choosing Hispanic or
Latino Origin means you are a person of Cuban,
Mexican, Puerto Rican, South or Central American or
other Spanish culture or origin, regardless of race.
Race: Check all below that apply.
☐ American Indian or Alaska Native
Choose from list.
Yes or No.
☐ White
☐ Asian
☐ I do not wish to self identify race/ethnicity
☐ Black or African American
☐ I do not have a 2nd race to identify
☐ Native Hawaiian or Other Pacific Islander
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