Internship Application Form (sample)

TABLE OF CONTENTS

Student Evaluation of Internship Experience

Internship Overview

Therapeutic Recreation Service

1) The therapeutic recreation internship shall be a minimum of 440 clock hours of an 11 week period worked at 40 hours each week. A 22 week 20 hours per week internship can also be accommodated during the school year.

2) The TR intern shall take on increasing responsibility in planning and leading TR groups and in their caseload.

3) The TR intern will conduct leisure assessments utilizing interviews and standardized evaluations.

4) The TR intern will document patient progress, conduct QA monitors, and service evaluations.

5) The TR intern will participate in treatment team meetings.

6) The TR intern will attend various workshops and inservices.

7) The TR intern will plan and implement a special event or special project of their choice.

Name: _____________________________________ Date: ________________

Current Address: __________________________________________________

Phone:__________________________________________________________

School Attending:__________________________________________________

Permanent Address:________________________________________________

Phone:__________________________________________________________

1. When do you want your internship to begin?

2. Work experiences using recreation or other activity therapy areas (Include length of time, age level, type of population, etc.):

3. Areas of strength in recreation and group process:

4. Areas of weakness in recreation and group process:

5. Can you lead or instruct the following activities?

____ team sports ____ aerobics ____ arts & crafts

____ weightlifting ____ cooking ____ games

____ tournaments ____ picnics ____ drama

____ other (list)

6. Have you had any experience in planning large group activities? If so, describe:

7. What do you see as your strengths and weaknesses as an individual?

8. What is your reason for desiring an internship at xxxxxxxxxxx Hospital?

9. What facets of therapeutic recreation interest you the most? (modalities, populations, etc.)

10. What facets of therapeutic recreation interest you the least?

11. Please ask two persons to write brief letters of reference for you, and enclose them with this application. These letters should refer to how long and in what capacity this person has known you.

a) A copy of your transcripts

b) Two letters of reference as noted above

c) Your resume

1. Before the internship begins you will be required to complete a physical exam and a TB test. You must bring a copy of the physical or a statement from your physician indicating your state of health. Result of the TB test is needed as well. In addition, you are required to carry your own professional liability insurance. Proof of this insurance is required.

2 This internship is designed for you to develop clinical skills in therapeutic recreation services. In addition, you are expected to utilize available opportunities to learn about other treatment services.

3. As a student in this program, you will be expected to develop appropriate clinical skills; to write accurate, professional notes and reports; and to relate to other staff in an efficient, professional manner.

4. You will be expected to relate to your team and to function in your clinical assignment as a full staff member by the end of the internship. This will include having a good working relationship with staff members, having a general knowledge of what each member does, and having an accurate perception of how each member functions as part of the team.

5. The supervisor(s) are responsible for providing quality supervision. Therefore, your internship supervisor will make every effort to provide constructive and positive direction so that learning can occur in a supportive manner.

6. The intern is expected to behave in a professional manner toward patients, staff, supervisors, visitors and other students. It is the intern’s responsibility to use supervision in an open, honest manner by bringing issues to be discussed to the supervisor.

7. It is the responsibility of the intern to complete assignments. If for some reason there is a problem carrying out the assignments, please discuss it with the person who assigned them to reach an agreement satisfying to both parties.

Sample Contract for Therapeutic Recreation Internship

A CONTRACT BETWEEN:

XXXXXXXX HOSPITAL

(herein referred to as Hospital)

AND

___________________________________________

NAME

(herein referred to as STUDENT)

_________________________________________________

ADDRESS

_____________________________

SOCIAL SECURITY NO.

Dated this __________ day of __________, ______. The purpose of this contract is to secure the professional services of _______________________, an undergraduate student of therapeutic recreation at _____(school)__________ from ______________ to __________________ to be rendered to xxxxxxxxxx Hospital.

A. WHEREAS, the STUDENT is willing to enter into this contract to provide services according to the terms and conditions set forth below:

1. The STUDENT will provide services for xxxxxxxxxx Hospital for 40 hours per week in accordance with the polices and procedures of xxxxxxxxxx Hospital and the requirements for a qualifying experience of the National Certification of Therapeutic Recreation Council & internship requirements for ______(your college)________.

Page 2

CONTRACT

2. The STUDENT will have received written approval from the (your college)____ Internship supervisor to begin this 440 hour qualifying experience.

3. Primary agency based supervision will be provided by xxxxxxxxxx, MS, CTRS, recreation therapist.

4. The STUDENT will receive travel expenses for job-related travel in accordance with personnel policies of xxxxxxxxxxx Hospital. This travel will not include commuting between the student's residence and xxxxxxxxxxx Hospital.

5. The STUDENT, under this contract, will not be eligible for employee benefits of xxxxxxxxxxx Hospital.

6. The STUDENT is required to carry his/her own professional liability insurance to provide xxxxxxxxxxx Hospital with a copy of such policy. Upon evidence of professional liability coverage, xxxxxxxxxxx Hospital will name _______your name___________ as an additional insured, provided that a written contract exists between the student and xxxxxxxxxxx Hospital.

7. The STUDENT is required to have completed his/her Junior year coursework in Therapeutic Recreation.

B. WHEREAS, the Hospital agrees to perform the following:

1. HOSPITAL shall provide orientation for the Intern to the Hospital's physical facilities and, where necessary, to the needs and requirements of individuals and/or groups with who the Student will be working.

Page 3

CONTRACT

2. HOSPITAL shall provide to Intern access to learning experiences in the Hospital, including opportunities for Student practice and observation and the facilities to provide the best learning experience for the Intern at a give level. Recreation Therapist shall provide direct supervision during individual and group patient treatment. Recreation Therapist shall review, approve, and provide co-signature for documentation that becomes part of the patient's medical record.

3. HOSPITAL shall provide an on-site supervisor certified by the National Council on Therapeutic Recreation Certification as a certified Therapeutic Recreation Specialist.

IN WITNESS WHEREOF, xxxxxxxxxxx Hospital executes this agreement by its duly authorized officer and the STUDENT does likewise, as of the day and year first written above.

_________________________________________          ___________ 
CEO, xxxxxxxxxxx Hospital                          Date

________________________________________           ___________ 
Director, Therapeutic Recreation Service           Date


_________________________________________          ___________ 
Recreation Therapist                               Date


_________________________________________          ___________ 
Student                                            Date

Student Selection Process

The procedure for securing a student internship at xxxxxxxxxxx Hospital is as follows:

1. Students desiring an internship will submit a letter of application at least three months prior to starting date.

2. Based on submitted paperwork, the site supervisor will request an interview by phone or in person.

3. The student selected for the internship will be notified at least two months prior to his/her starting date.

In order to offer a comprehensive experience to the student, only one therapeutic recreation student will be accepted per 11 week period Students must meet the following prerequisites for placement as intern:

1. Minimum of 9 hours of psychology classes

2. Nine hours of course work in therapeutic recreation from an accredited college or university.

3. Junior or higher standing.

The expectations of the clinical involvement of the students are as follows:

1. Complete a minimum of 440 clock hours of an 11-week internship worked at 40 hours each week.

2. Participate in Departmental meetings.

3. Join in non-TR activities (occupational therapy, community meetings, etc.)

4. Participate in unit team meetings and staffings as scheduled.

5. Take on increasing responsibility in planning and leading therapeutic recreation groups. This include writing treatment objectives, dealing with group and individual issues, and evaluating programs.

6. Participate in weekly evaluation with your site supervisor.

7. Chart pertinent information on patient progress.

8. Attend pertinent hospital inservices.

9. Fulfill all assignments.

10. Complete a final report of the internship experience.

The Rehabilitation Therapy Department of xxxxxxxxxxx Hospital expects the following involvement from the college/university:

1. A specific faculty member will be assigned as the student’s advisor during the course of the internship.

2. The student advisor will provide consultation to the student and site-supervisor as needed.

3. The student will be provided with the necessary educational background for the field placement.

4. The agency will be provided with updated school internship manuals.

xxxxxxxxxxx Hospital will:

1. Provide a formalized orientation program for the student.

2. Provide a final evaluation to student and to the student’s advisor.

3. Provide consistent counseling and feedback to the student during the internship.

4. Provide equal consideration of prospective interns without discrimination.

5. Appoint a supervisor who is certified with the National Council for Therapeutic Recreation Certification and who has at least two years of experience in therapeutic recreation.

Week 1:

· Orientation to facility, program and staff.

· Observe programs, develop rapport with staff and patients, and gather information needed for comprehensive program planning.

· Discuss special projects ideas with supervisor (implementation time-line for special projects will depend upon each project).

· Review policies and procedure manual

· Review safety plans

· Review patient rules for each unit

· Review patient charts

· Review Approved Terminology and Abbreviation List

· Review Error Correction Policy and Documentation Policy

· Review Confidentiality and Patient Relationship Policy

Week 2:

· Continue gathering information about xxxxxxxxxxx Hospital , the patients, the community, etc. that will help in program planning.

· Begin developing a comprehensive program plan with specific activities and treatment objectives (student will be responsible for at least one group session per day).

· Continue to observe TR groups and other groups. Co-lead several groups.

· Write progress note on a single patient following each group. Obtain feedback.

· Attend TX meetings.

· Conduct initial interview/assessment with a patient.

Week 3:

· Submit the comprehensive program plan for review and feedback.

· Initiate one group session. Obtain feedback and generate a brief report.

· Continue to develop program plans for other groups in the coming weeks.

· Begin contribution to patient's TX plan and take an increasing role in the patient's TX team meeting.

· Continue with additional initial interview/assessments.

Week 4:

· Implement additional group sessions (2nd and 3rd).

Week 5:

· Implement the remainder of group sessions (4th & 5th).

Week 6:

· Continue to implement group activities, assess clients, write progress notes, participate in TX meetings.

· Submit finalized comprehensive program plan.

· Select a single patient to do a case study.

Week 7:

· Continue with given duties.

· Submit case study for review & feedback.

Week 8:

· Continue with given duties.

· Submit finalized case study.

Week 9:

· Continue with given duties.

· Develop plan to visit at least 2 area facilities with therapeutic recreation services.

Week 10:

· Continue with TR services.

Week 11:

· Wrap up projects.

· Submit internship report

· Participate in an exit interview with internship supervisor.

Please rate your present level of ability in the following areas.  
Circle the number which most closely represents your status within 
these guidelines:
1-Poor  2-Below Average  3-Average  4-Above Average  5-Superior

                                         	                         Initial 	                                          Final

Knowledge of assigned patient population

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Confidence in initiating new programs

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Skill in planning activities

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Creativity

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Communication skills

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Ability to deal with constructive criticism

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Leadership skills

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Emotional stability	

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Physical fitness

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Adaptability

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Decision-making skills

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Organizational skills

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Problem solving skills

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Time management skills

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Seeking help when necessaryv

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Accepting supervision

1

 2

 3

 4

 5

1

 2

 3

 4

 5

Final evaluation only.

Based on your internship experience, in what areas do you feel you 
have developed?

Student Evaluation of Internship Experience

Please complete this evaluation and mail it to:

Name
Adolescent Unit 
xxxxxxxxxxxHospital
930 xxxxxxxxxxxRoad
City, State, Zip

Name:

Dates of Internship:

Site Supervisor:

xxxxxxxxxxx Hospital desires to continually upgrade its internship experience. As the consumer of this learning experience, you are in the best position to give us feedback. Please be as honest and specific about each item as possible. Your grade will be determined before this evaluation is read and discussed. Add additional comments on a separate page as needed. Thank you!

------------------------------------------------------------

1. Orientation Program

Please rate your orientation experience at xxxxxxxxxxx Hospital

4- Orientation to xxxxxxxxxxx Hospital was excellent

3- Orientation to xxxxxxxxxxx Hospital was beneficial

2- Orientation to xxxxxxxxxxx Hospital was informative but disorganized

1- Orientation to xxxxxxxxxxx Hospital was provided but given later in the internship

0- Orientation to xxxxxxxxxxx Hospital not provided

2. The TR Internship Experience

a. Please indicate what experiences have been most helpful in preparing you for the TR profession? Consider individual and group interactions and other aspects of the internship.

b. Which experiences have been least helpful in preparing you for the profession?

c. Which staff at xxxxxxxxxxx Hospital were helpful role models in client interaction?

d. Did you find a correlation between theories and concepts learned at the university/college level and practical applications at this agency? Describe.

e. Was the amount of responsibility you were given adjusted to your professional growth?

f. From your observations, are the Therapeutic Recreation services provided at xxxxxxxxxxx Hospital beneficial to the clients? What would you add, change or delete?

h. Are there any items of equipment, supplies, or conditions which you feel should be provided or improved to permit interns to have a more positive learning experience?

3. Supervision

Please rate your supervision

4- Consistently exceeded what was expected

3- Frequently exceeded what was expected

2- Consistently met expectations

1- Occasionally failed to meet expectations

0- Consistently failed to meet expectations

In what ways has your supervisor been most helpful?

Could you suggest alternative methods to improve supervision and guidance?

4. Assignments

What specific changes would you make in the amount and format of assignments given to you during your experience?

5. Summary

a. What do you see as the strengths of the internships program at xxxxxxxxxxx Hospital?

b. What do you see as the weaknesses of the internship program? What changes would you make?

c. Would you recommend this agency as an internship experience?

d. Do you feel that you have been trained to be a beginning Therapeutic Recreation Specialist?

6. Additional Comments:

April 22, 1994

Supervisor's Name xxxxxxxx

Address xxxxxxx

Dear xxxxxx:

xxxxxxxxx as been accepted as therapeutic recreation intern at xxxxxxxxxxx Hospital. She will begin May 4, 1994 and work for a period of ten weeks in order to meet 440 hours of internship experience.

Her duties will include assignment to individual cases, developing individualized treatment plans, implementing therapeutic recreation programs, documenting patient progress, observing various treatment groups in the hospital, and participating in treatment team and staff meetings.

Sincerely Yours,

xxxxxxxxxxx xxxxxxx, CTRS