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.

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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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