Fellowship Application

APPLICATION DEADLINE August 3, 2022


Fellowship Start Date *
Only select one and it must coincide with when you begin internship. Occupational Therapy students follow the guidelines given by Dr. Seruya

Demographics

Name*
Address*

Background

I identify my sex as…*
I identify my gender as…*
Race *
Are you Hispanic/Latino *
Are you a first generation student*
Are you fluent in Spanish (reading and writing with proficiency) *

Training

Program of Study*
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
Field Placement Full Name *
https://data.hrsa.gov/tools/shortage-area/by-address

Essay

Provide a 500-word essay as to why you wish to provide behavioral health services to children, adolescents, and transitional-aged youth (e.g. college age) who are at risk for behavioral health disorders in high need high demand areas after graduation

No File Chosen
File uploads may not work on some mobile devices.

Signature

If selected, I agree to comply with the IHELP standards:

•To complete 5-7 hours per month of additional education including activities such as webinars and interprofessional events.

•To work be open with working with children, adolescents, and transitional-aged youth and families in the Bronx or a medically underserved area 

•To provide demographic information during the internship experience

•To discuss fellowship with Site Supervisor to receive training as well with compensation.

•To be open with working in behavioral health with children, adolescents, and transitional youth in economically disadvantaged and underserved communities after graduation.

•To provide post-graduation information

Use your mouse or finger to draw your signature above