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Integrated Behavioral Health Pipeline Program – Applicant Application

Contact Information

Name(Required)
Email(Required)
Address(Required)

Demographic Questions

MM slash DD slash YYYY

Education & Availibility

MM slash DD slash YYYY
What days do you usually have class?(Required)
What days do you plan on completing your internship?(Required)
What days of the week would you prefer group didactic sessions to occur?(Required)

Internship Placement

Have you applied to a community health center for placement?(Required)
To be eligible for the program, you will need to be placed at one of our member health centers. Visit: https://ccalac.org/member-clinics/ to view which health centers are part of our association.
Have you been interviewed by the health centers already?(Required)

Personal Insight Questions

Application Completion(Required)
Clear Signature

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