Clinic Training Interest Form

Please review the Clinic Training Info Sheet thoroughly before submitting the Interest Form. If your Interest Form is selected for a screening (step 2 in the application process), you will receive a response from maryanneboston@stlpi.org within 2 weeks to schedule your screening.

Clinical trainees who have a record are encouraged to notify the Clinic Team of this information in writing (see instructions below for Special Circumstances) as part of their application to the Clinic Training Program. Potential clinical trainees with a record will be evaluated on a case-by-case basis by Institute leadership to determine whether a relationship with the Schiele Clinic is appropriate.

Please Check Each Box Below

I understand that this program is a 12-month commitment.
I agree to complete a comprehensive background check prior to enrollment in the Clinic program.
I understand the Time Requirements presented on the Clinic Training Info Sheet and agree to them.

First Name*

Last Name*

Preferred Name

Pronouns*

Email*

Enter Email Confirm Email

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Clinic Training Interest Form

Step 1 of 4

Documents

Training Program Timeline

Please list 2 references for us to contact for recommendation letters.