Graduate Student Placement ApplicationCST Academy is dedicated to providing opportunities for aspiring clinicians through our practicum and fieldwork placement program. Please complete the form below to be considered for a placement with our team. Name* First Last Field of Study* ABA Therapy Occupational Therapy Physical Therapy Speech-Language Pathology Email* Phone*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Graduate School* How many placements have you already completed?*01234What settings were these placements in? (Check all that apply)* Adults Pediatrics School Private Practice Hospital Skilled Nursing Facility If offered an interview, are you willing to travel to our office in Chicago? Yes No Does your school already have an affiliate agreement with our practice? Yes No I'm not sure Placement Coordinator Contact InformationName* First Last Email* Phone*Dates of PlacementAnticipated Start Date (Month)*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAnticipated Start Date (Year)* Anticipated End Date (Month)*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAnticipated End Date (Year)* Anticipated Days of the Week* Monday Tuesday Wednesday Thursday Friday I'm Not Sure Short EssayTell us about yourself and why you are interested in our program for your placement.Tell us a little bit about your interest in the field. What are you passionate about?Tell us a little bit about your interest in the field. What populations are you interested in working with after graduation?File UploadsUpload Resume*Max. file size: 100 MB.Upload Video*Max. file size: 100 MB.Include a video with your application here. Don't worry, you don't need to be Steven Spielberg. Let your unique personality shine by telling us about your background experiences and why you are interested. Δ
