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

Training Program Timeline
Preferred Start Date
MM slash DD slash YYYY
Second Preference Start Date
MM slash DD slash YYYY
Preferred End Date
MM slash DD slash YYYY
Second Preference End Date
MM slash DD slash YYYY
Special Interests

Please list any interests during your academic or professional career

Please list 2 references for us to contact for recommendation letters.
Please list two references with their phone number and email. If your Interest Form is selected for a screening and you pass the screening, two recommendation letters will be required to complete your application. Your letters should be written by your references and your references should email the letters directly to maryanneboston@stlpi.org. Your submission of this form indicates that you give your permission for us to contact your references.
References
Special Circumstances: Please consider any special circumstances that may affect your participation in this program (financial concerns, scheduling or personal issues, issues with background check). Email maryanneboston@stlpi.org with these considerations.
Preferred contact method:
- Email
- Phone
- Mail
How did you hear about this Program?*
- Email
- Flyer
- Word of mouth
- Other
Consent
I agree to the privacy policy.
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