Internship Site Summary

Please fill out the following summary of your agency and attach any available program information (e.g., literature or brochures) regarding the services your site provides.

SITE INFORMATION

Name of Agency: __ D&D Psych., Inc.______

Agency/program Website: ___www.ddpsych.com______

Address: _7392 NW 35 th Terrace, Suites 201/202, Miami, Fl 33122 ___

Phone: __(305)597-9494______Fax: (305)597-9495______E-Mail: [email protected]______

Stipend: ____Yes __x_ No Amount per semester: $______n/a______

Site Representative: _ _Gabriela Raurell______

Primary Intern Supervisor: _____Gabriela Raurell______

License #: _MH-5230______Date first Licensed: ___1999______

Highest Degree: _Master’s Mental Health Counseling______Institution: __Nova Southeastern University______

Site Practice Domain: ___ Forensics/Corrections __x_ Eating Disorders (Check all that apply) _x__ Substance Abuse ___ Developmental dis. _x__ Crisis Intervention __x_ Abuse/Trauma __x_ Geriatrics _x__ Chronic Mental Illness ___ Other: ______

Setting: ___ Hospital ___ School ___ Correctional Institution ___ Residential ___ Group Home __x_ Outpatient __x_ PHP ___ Other: ______

TRAINEE INFORMATION:

Number of trainees needed per semester: __3______Number of days _5____ and hours _20__ _ per week available for students to work.

Days/hours Flexible: _x___ Yes ____ No, explain: ______

Evening and weekend hours available: ____ Yes _x__ No

Special skills required: ______Attendance required at particular meetings: ______DESCRIPTION OF CLINICAL EXPERIENCE

Description of agency/program: ______

Experiences that students will engage in, check all those that apply:

___ Assessments ___ Therapy ___ Couples/family therapy ___ Group Therapy ___ Report Writing ___ Consultation ___ Other: ______

Supervision Description: ______

___ # of supervision hours that agency will provide supervision per week.

CLIENT DESCRIPTION INFORAMATION

Population: ___ Adult ___ Child ___ Adolescents ___ Couples ___ Families ___ Geriatrics

Race/Ethnicity: ___ Caucasian ___ Native American ___ African American ___ Asian ___ Hispanic ___ Appalachian ___ Other: ______

Special Needs: ___ Physically Challenged ___ Developmentally Disabled ___ Visual/hearing impaired

Presenting Problems (please rank the top three presenting problems): __ Anxiety __ Domestic Violence __ Phobias __ Chemical Dependency __ Job-related __ Psychosis __ Chronic Pain __ Learning/academic __ PTSD __ Delinquency __ OCD __ Depression __ Relationship Issues __ Parenting __ Stress __ Divorce __ Personality Disorder __ Other: ______

Other Information about your agency/site, which would be help for prospective trainees: ______

Please return form via email to Lisa Lewis Arango, [email protected]