Postgraduate Fellowship in Clinical Social Work
The Menninger Clinic, 12301 Main St., Houston, TX 77035
Fellowship Application
Date:
Name:
(Last, First Middle)
Mailing/Address:
(Street, City, State & Zip)
Phone: (Home)
(Work)
(Cell)
Email:
Sex:
(M)
(F)
Citizenship:
US
Other
Any significant medical or physical condition:
I.
Undergraduate Education
A. College Degree Year:
Major:
B. Graduate School Degree Year:
1.
Concentration/ Major:
Type of Program:
Clinical:
Other (specify):
CSWE approved:
2.
Yes
No
Master’s Thesis Title: (If applicable):
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II.
Clinical Experience:
A. Psychotherapy cases seen
(Please write in approximate number of adult (A) and child (C)
1. For each category both reflecting field and postgraduate experiences for "Total"
category).
2. Total individual psychotherapy cases A
C
3. Individual, long term A
C
4. Individual, short term A
C
5. Insight, Psychodynamic-Oriented A
C
6. Crisis Intervention A
C
7. Group (list age ranges ) A
C
8. Family Therapy, Systems Approach
9. Marital
10. Other (specify): A
C
B. Supervision
(Indicate approximate number of hours of clinical supervision)
A
C
III.
Why are you interested in the Menninger fellowship?
IV.
What do you consider your strengths and weaknesses?
11. Professional Strengths:
12. Professional Weaknesses:
13. Personal Strengths:
14. Personal Weaknesses:
Please send the following:
A. Graduate transcript - (official)
B. Resume
C. Three (3) letters of reference (at least two must be from field or other clinical supervisors)
D. Field evaluations
E. Clinical paper or narrative report (de-identified clinical report that includes presenting
problem, history, current symptoms, diagnostic formulation, treatment goals and intervention
approaches) with approximately 2 pages of process recording included.
*We request that all application components be sent in one package. Recommendation
letters should be signed and sealed separately within the package, with the recommender’s
signature over the seal. Official Graduate Transcripts can also be included in the package if
they are sealed by the registrar. The package should be postmarked by February 1, 2016.
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Application Deadline: February 1, 2016
Send to:
The Menninger Clinic
Attn: Cynthia Ramanujam
12301 Main St
Houston, TX 77035
For questions please contact Cynthia Ramanujam, 713-275-5357
Cynthia Mulder, LCSW
Director of the Social Work Fellowship
The Menninger Clinic
12301 Main St
Houston, TX 77035
713-275-5247
cmulder@menninger.edu
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