<p> Internship Site Summary</p><p>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. </p><p>SITE INFORMATION</p><p>Name of Agency: __ D&D Psych., Inc.______</p><p>Agency/program Website: ___www.ddpsych.com______</p><p>Address: _7392 NW 35 th Terrace, Suites 201/202, Miami, Fl 33122 ___</p><p>Phone: __(305)597-9494______Fax: (305)597-9495______E-Mail: [email protected]______</p><p>Stipend: ____Yes __x_ No Amount per semester: $______n/a______</p><p>Site Representative: _ _Gabriela Raurell______</p><p>Primary Intern Supervisor: _____Gabriela Raurell______</p><p>License #: _MH-5230______Date first Licensed: ___1999______</p><p>Highest Degree: _Master’s Mental Health Counseling______Institution: __Nova Southeastern University______</p><p>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: ______</p><p>Setting: ___ Hospital ___ School ___ Correctional Institution ___ Residential ___ Group Home __x_ Outpatient __x_ PHP ___ Other: ______</p><p>TRAINEE INFORMATION:</p><p>Number of trainees needed per semester: __3______Number of days _5____ and hours _20__ _ per week available for students to work.</p><p>Days/hours Flexible: _x___ Yes ____ No, explain: ______</p><p>Evening and weekend hours available: ____ Yes _x__ No</p><p>Special skills required: ______Attendance required at particular meetings: ______DESCRIPTION OF CLINICAL EXPERIENCE</p><p>Description of agency/program: ______</p><p>Experiences that students will engage in, check all those that apply:</p><p>___ Assessments ___ Therapy ___ Couples/family therapy ___ Group Therapy ___ Report Writing ___ Consultation ___ Other: ______</p><p>Supervision Description: ______</p><p>___ # of supervision hours that agency will provide supervision per week.</p><p>CLIENT DESCRIPTION INFORAMATION</p><p>Population: ___ Adult ___ Child ___ Adolescents ___ Couples ___ Families ___ Geriatrics</p><p>Race/Ethnicity: ___ Caucasian ___ Native American ___ African American ___ Asian ___ Hispanic ___ Appalachian ___ Other: ______</p><p>Special Needs: ___ Physically Challenged ___ Developmentally Disabled ___ Visual/hearing impaired </p><p>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: ______</p><p>Other Information about your agency/site, which would be help for prospective trainees: ______</p><p>Please return form via email to Lisa Lewis Arango, [email protected] </p>