Application for Admission
Drug and Alcohol Recovery Counselor Internship

Name _________________________________________________________ Address___________________Town _________________Zip________ Phone________________________day__________________evening____________ Email_______________________________________________________________

I hope to enter the internship in the fall semester of 2007

Application Check List

1. I am submitting a copy of my college transcripts.

Yes_____ No_____

2. I am a matriculated student at Gateway Community College and have declared myself a DARC major through the Registrar’s Office.

Yes_____ No_____

3. I have given the Faculty Evaluation form to my DARC 101 and 111 instructors and requested that they complete it and submit it to the DARC coordinator.

Yes_____ No _____

4. I have requested 2 letters of recommendation.

Yes_____ No _____

5. I have submitted my personal statement.

Yes_____ No _____

6. It has been at LEAST 18 months since I have had an active addiction, or I have never had an addiction. I agree that I must be at least two years substance-free in order to begin the Internship.

Yes_____ No ____

7. I am free from all illicit substances.

Yes______ No ______

8. I have completed, with a C or better, or am currently enrolled, in DAR 101, 111, 112, 158 and ENG 120.

Yes______ No ______

I understand a breech of the Counselor Code of Ethics, CFR 42 part 2, or HIPAA may result in my being dismissed from the internship. 

Signed__________________________________________________________________

Date____________________________________________________________________

Note – Internship must be 2 consecutive semesters Fall to Spring. If a student completes DAR 251 but does not complete DAR 252, the entire internship will need to be repeated.