Intern/Practicum Pre-Interview Questionnaire

    First and Last Name

    Email Address

    Where are you enrolled in school?

    Are? Were you involved in any extra-curricular activities?

    How did you get along with your classmates and teachers / professors?

    Are you currently employed?

    If yes, where at and what kind of work?

    Do you enjoy your present work situation?


    Do you have any special Job skills or training

    How well do you get along with your boss / supervisor?

    How well do you get along with your co-workers?

    Do you have any problems with being late or absent to work?

    Have you ever been fired from a job before?

    Previous Related Jobs or volunteer experience

    Have you ever received services from The Refuge Center before?

    What relationships have the greatest influence in your life right now?

    Has there been an event in your life (either positive or negative) which was so intense that it permanently affected your outlook on life? (If yes, please describe briefly)

    What beliefs or values have been most important in guiding your life?

    What feelings or emotions do you have when you think of God; is there any particular image that comes to mind?

    Is your faith / spirituality helpful to you?

    Is there anything you do to help nurture or maintain your faith / spirituality?

    What role(s) did you play in your family of origin?

    Talk about your primary and secondary responses to feedback: fight, flight or embrace?

    How do you inspire trust from the people you are serving?

    How would you define compassionate care?

    Provide examples of times you demonstrated diligence, compassion, courage, commitment, and perseverance.

    Please answer the following questions in 1-3 sentences.

    How did you hear about The Refuge Center and what interested you about our agency?

    How would you define clinical excellence?

    What Types of therapy are you most interested in?

    What population do you see yourself working most with?

    What is your experience with that population?

    What is your schedule availability / flexibility?

    What types of continuing education opportunities do you engage in?

    Review the following case examples and write a treatment plan outline that you would follow based on the client presentation.

    Case Example 1:

    A 35 year old female comes to the initial session complaining of physical aches and pains the doctors cannot explain. She states that her doctor recommended she come to a therapist. She explains that she has had several instances of shortness of breath and feeling like she was going to die. She also complains of having difficulty sleeping. She has been married for 10 years to the same man and has 3 children. Throughout the session she glances toward the door frequently and is easily startled by noises coming from the hallway. Her symptoms checklist also includes persistent worry, guilt, fatigue, and nightmares. When you ask the client if it is okay to contact her at home, she immediately tightens in the chair and asks if no one contact her but if it is okay for her to contact the agency as needed.

    Case Example 2:

    A mother calls for her 8 year old son who is having behavior problems at school. The boy has had a decline in his grades over the last several months and is constantly getting in trouble in the classroom for small disruptions like talking when he is not supposed too, getting out of his seat, and disturbing those around him with noises in class. The mother states he has been showing some aggression at home with his siblings, and has been refusing to follow directions and do his chores. The mother states that the client’s father is not involved in the child’s life. She was married a year ago to a man with whom she has a 4 year old. The mother states that her husband is the only father the 8 year old has ever known. The mother mentioned that her and her husband differ on discipline and argue often when it comes to the 8 year olds behavior.

    • When I first came to The Refuge Center, I had an eating disorder. Now I am not worried about food or my weight. I am happy and have more joy. I am not worried or anxious.

      Female, Age 17
    • The Refuge Center has taught me so much about myself. I’ve discovered who I am in a bright, new way. I’ve learned how to work through pain of loss, relationship problems, and I’ve learned how to set healthy boundaries. After all, it’s up to me to protect myself. I’ve also learned that I’m not damaged, or maybe I am, but we all are and we all can heal. The Refuge Center has taught me how to take steps towards healing. It’s a journey, but a beautiful one. I’m learning to find joy in the “here and now”.

      Female, Age 27
    • My family and I came to The Refuge Center after experiencing several traumatic deaths in our immediate family.  We were eagerly met with patience, love, concern, and understanding of our situation.  They have offered tremendous guidance and excellent suggestions to help us cope.  We feel blessed that God guided us to such an amazing center!

      Family testimonial
    • I can’t begin to tell you how thankful I am to have received help from the Refuge Center.  My therapist has been amazing!  When I came to the center, I felt devastated, guilty, unloved and overwhelmed.  My therapist helped me see things in such a different light.  She gave me tools to use and listened to me cry.  She gave me courage and hope.  She truly has been an angel sent to me from God.  As I sit here today, I feel confident and stronger than I ever have!  I am forever thankful for all your help.  Thank you, thank you, thank you!

      Female, Age 40
    • Talking to my counselor has been life changing.  She helped me understand things fully, like with friendships, family problems, and my own feelings and emotions.  I’m really thankful for her help.  Even though I’ve never been to another counselor, I’m pretty sure she’s the best ever!  It’s great to have someone to talk to other than friends and family. Thank you.

      Female, Age 14