Fax Us Your Rule 25 Referral: (320) 963-6279 or Call (651) 338-3317

Internship Application


Personal Information

Will you be 21 years of age by the start of your internship? DHS requirement for direct care contact


Please supply a copy of your transcript and the current internship evalution form used by your field instructor with your application. Please email or fax, (320) 963-6279, us these documents.

Employment History (Begin with the most recent)

Intership Time Period

What is the length of the internship you are requesting?

Personal Recovery and Stability

Are you currently chemically free?

To applicants who are in chemical dependency recovery or recovery from other addictions or mental health issues:
Maple Lake Recovery Center, Inc. requires that applicants whose lives have been directly affected by these issues have at least two years of personal recovery. MLRC defines recovery as an active process of change and growth facilitated by one of more of the following: Twelve Step programs, counseling, therapy, spiritual guidance, or sponsorship.

If you are in recovery, do you have at least two years of continuous recovery?
If you are not chemically dependent, please describe how you currently use of mood altering chemicals (including alcohol, prescribed and over the counter medications):
If you are in recovery problem other than for chemical dependency, please describe your dates and types of treatment:


Please list the names of two people not related to you, who can verify the length of your abstinence or involvement in a Twelve Step or other recovery program.

Please list as personal references two people, not related to you, whom you have known at least two years. (List names other than above.)

Internship Application Questionnaire

The following information is to help us understand your skills, goals, needs, and strengths. Attach additional sheets if necessary.

1. Previous Field of Placements
List any previous field/clinical placements you have had:
2. Academic Classes or Skills Training:
List any coursework or skills training that would be relevant to an internship. (e.g., Human Development, Abnormal Psychology, Theories of Counseling, Assessment)
3. Availability:
Considering the requirements for your academic program and other commitments in your life, how much time can you realistically allocate to this placement each week? Please be specific about days and times you will or will not be available.
4. Knowledge of 12 Step recovery Programs:
Please describe your familiarity with 12 step recovery programs:
5. Treatment Settings:
What treatment setting would best match your abilities and interests at this time?
Indicate any prior course work or experience relating to such settings.
6. Clients Served:
What type of clients (e.g. ages, presenting concerns, ethnic or cultural backgrounds) is you most interested in working with at this point in your training?
Indicate any prior courses, training, or experience working with this group
7. Treatment Approach:
What theoretical orientation or treatment approach is most interesting to you at present?
8. Learning Opportunities:
What sorts of learning opportunities do you hope to have at your internship and what level of involvement and responsibility would you like?
9. Supervision Style and Personality:
What personal qualities of a supervisor do you think you would work with best?
10. Career Plans:
What experiences will be most useful in helping your candidacy for a job or academic admission?
11. Limitations, Safety, and Risks:
List any concerns you might have about the limits of your abilities or knowledge:
Identify any concerns or questions you have about safety issues relating to placements:


I understand that the facts contained in this internship application are true and complete to the best of my knowledge and, if employed, I understand that falsified statements on this application may be grounds for dismissal.

I authorize inquiries of all statements contained herein and the reference and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for internship for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

Consent to MN Department Of Human Services Background Study

Have you lived in prior states within the U.S. other than Minnesota in the past 5 years?
Other names I have been known as, such as maiden or previously married name:

Please review application