Tranquil Lotus Mental Health

Intern Application

Tranquil Lotus Mental Health offers free clinical supervision toward licensure provided by Sarah "Katie" Davis, LCSW, at a board-approved site for interns. I supervise practicum students, CSW-I, MFT-I, and CPC-I.

Complete the intern application below. I will review your submission and be in touch.

Authorization for background and credential verificationBy submitting this application, you authorize Tranquil Lotus Mental Health to verify your licensure, education, board standing, exclusion lists (including OIG and SAM), and professional references, and — after a conditional offer — to conduct a background check. A separate standalone disclosure and authorization form, and the identifying information needed for it, will be requested only through a secure form after a conditional offer. Misrepresentation on this application may result in denial of the application or termination.

Please also email the following to [email protected]: a copy of your intern license, your resume or CV, a copy of your degree or transcript (if requested), and a government-issued photo ID for credential verification (if requested after a conditional offer).

Name

Phone

Legal first name

Legal last name

Preferred / professional name (if different)

Pronouns (optional)

Mailing address (street, city, state, ZIP)

Preferred contact method

Highest degree & field

School / university

Year degree conferred

Board standing (confirm good standing with each licensing board above, or explain any conditions)

Reference 1 — name & credentials, relationship, phone, email (do not list family members)

Reference 2 — name & credentials, relationship, phone, email

Reference 3 — name & credentials, relationship, phone, email

Professional standing disclosures — answer Yes or No to each: (1) License ever revoked, suspended, surrendered, placed on probation, or otherwise disciplined? (2) Complaint, investigation, or disciplinary action currently pending? (3) Ever excluded, debarred, or terminated from Medicare, Medicaid, or any federal/state health care program? (4) Malpractice coverage ever denied, cancelled, non-renewed, or claim filed? (5) Currently unable to perform essential clinical duties, with or without reasonable accommodation? If Yes to any, explain with dates, agency/board, outcome.

Authorization for background & credential verification

I agree / I authorize

Signature — type your full legal name

Date signed

Intern license type

Intern license number

Printed name

Message

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