Children's Memorial Hospital
Ann & Robert H. Lurie Children’s Hospital of Chicago
Medical Art Therapy Internship Application
Fall 2020- Spring 2021
PLEASE TYPE or PRINT CLEARLY
DEADLINE: February 14th, 2020
Name _________________________________ Phone (Day) _____________ (Evening) _______________
Address ____________________________________ City _____________ State ______ Zip ____________
E-mail address _______________________________ Birthday: (Day/Month only)_____________________
Academic Background
University/College ______________________ Dates Attended (Month/Year) From _________ To _________
Major _________________________________ Minor/Areas of Emphasis _____________________________
Graduation Date _____________________ Degree Earned _____________________________ GPA _______
University/College ______________________ Dates Attended (Month/Year) From _________ To _________
Major _________________________________ Minor/Areas of Emphasis _____________________________
Graduation Date _____________________ Degree Earned _____________________________ GPA _______
Courses in Child Development, Child Life, Art Therapy, Expressive Therapies or Related Medical Courses*
(Completed or in process of completion)
Course Title Grade Earned
1. __________________________________________________________________________ ____________
2. __________________________________________________________________________ ____________
3. __________________________________________________________________________ ____________
4. __________________________________________________________________________ ____________
5. __________________________________________________________________________ ____________
6. __________________________________________________________________________ ____________
7. __________________________________________________________________________ ____________
8. __________________________________________________________________________ ____________
9. __________________________________________________________________________ ____________
10. __________________________________________________________________________ ____________
*Please include
Experience with Hospitalized Children
Art Therapy Fieldwork/Practicum*_____ Yes______ No (If no, please continue to next section)
Name of Institution ______________________________________ Department _______________________
Address __________________________________________________________________________________
Dates (Month/Year) From _________ To __________ Hours per week _________ Total Hours ___________
Briefly describe population and responsibilities ___________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Practicum Supervisor _______________________________ Telephone Number _______________________________
*Please attach a copy of your certificate of completion or a letter from your supervisor
Hospital or Health Care Volunteer Experience* ______ Yes _____ No (If no, please continue to next section)
Did you work with a pediatric population? ______ Yes ______ No
Were you supervised by a Child Life Specialist? _____ Yes _____ No or Art Therapist? _____ Yes _____ No
Or Other?______________________________
Name of Institution ___________________________________________Department ____________________________
Address __________________________________________________________________________________________
Dates (Month/Year) From _______ To _________ Hours per week _________ Total hours ______________________
Briefly describe population and responsibilities ___________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Volunteer Supervisor ___________________________________ Telephone number ____________________________
* Please attach a letter from your supervisor that includes a brief description of your experiences and hours completed.
Art as Therapy Based Work Experience _____ Yes _____ No (If no, please continue to next section)
Name of Institution ___________________________________________Department _____________________________
Address ___________________________________________________________________________________________
Dates (Month/Year) From __________ To _____________ Hours per week ___________ Total hours ______________
Briefly describe population and responsibilities ___________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisor _________________________________________ Telephone number _______________________________
Other Experience with Children, Adolescents and Families
(do not repeat experiences listed previously on this application)
Name of Agency __________________________ Experience related to ___ work ___school ____ volunteering
Address ______________________________________ Position/Title_________________________________ Dates (month/year) From _________ To __________ Hours per week _________ Total hours __________
Briefly describe population and responsibilities ___________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisor ________________________________________ Phone Number ___________________________________
Name of Agency __________________________ Experience related to ___ work ___school ____ volunteering
Address ______________________________________ Position/Title______________________________________
Dates (month/year) From _________ To __________ Hours per week _________ Total hours __________
Briefly describe population and responsibilities _________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Supervisor ______________________________________ Phone Number ____________________________________
Name of Agency __________________________ Experience related to ___ work ___school ____ volunteering
Address ______________________________________ Position/Title______________________________________
Dates (month/year) From __________ To ___________ Hours per week _________ Total hours __________
Briefly describe population and responsibilities _________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Supervisor ________________________________________ Phone Number __________________________________
Professional, School and Community Involvement
List organizations you are currently or recently involved in __________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
References
Please provide three letters of references (in sealed and signed envelopes, or by having the references email arttherapy@ directly) including at least one professional who has seen you interact with children. References can include professionals previously mentioned on this application and professors who know you well.
Use this space to write about your knowledge of art therapy and your previous life experiences, work experiences and how they have helped prepare you for a medical art therapy internship at Lurie Children’s.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
School Enrollment Information
Which Art Therapy Graduate School are you currently attending_____________________________________________
School site supervisor _______________________________________________________________________________
Address ___________________________________________________ Phone Number __________________________
Please Enclose
___ Practicum certificate OR letter from your supervisor indicating academic good standing
___ Your current resume
___ 3 letters of references (can be emailed directly from the reference or enclosed in a signed and sealed envelope)
___ Unofficial transcript from schools attended prior to art therapy graduate program
I confirm that the information provided in the application is true to the best of my knowledge. I further understand that any false statements on the application shall be sufficient cause for rejection for this internship or immediate discharge when discovered.
I hereby authorize my former supervisors and references to release information regarding my past experiences to assist this committee in determining my suitability for the internship.
Applicant's signature _____________________________________________ Date _____________________
Please return, via snail mail or email, completed application and additional materials to:
Willow Messier, MAAT, ATR-BC, ATCS, CCLS
Senior Art Therapist, Hematology/Oncology
Art Therapy Internship Coordinator
Ann & Robert H. Lurie Children’s Hospital of Chicago
225 East Chicago Avenue, Box 31
Chicago, IL 60611
Please direct any questions to arttherapy@.
The Ann and Robert H. Lurie Children’s Hospital of Chicago’s internship selection committee does not discriminate on the basis of race, creed, ancestry, color, religion, sex, national origin, age, marital status or disability. We reserve the right to not offer the internship every year.
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