Application for NP Students

Name *

First Name

Last Name

Phone Number *

(###)

###

####

Do you have WhatsApp?

Once trainees sign up we make a group chat on WhatsApp so that our team members can work with you most directly and efficiently

Yes

I can download it

I prefer to avoid using WhatsApp if possible

Gender

Female

Male

Other

University

Walden University

Chamberlain University

Purdue University

Maryville University

George Washington University

National University

Charles Drew University

Bowie State University

University of South Alabama

Herzing University

Brandman University

Liberty University

Wilkes University

Husson University

Other

Specialty Track of Student

PMHNP (Master's)

PMHNP (Post-Master's)

Other

Select your class

(For Walden PMHNP programs)

(Walden U) PMHNP 6635 Ind. Psychopathology

(Walden U) PMHNP 6645 Ind. and Group/Family Therapy

(Walden U) PMHNP 6665 Child/Adolescent Psych Mix Pt. 1

(Walden U) PMHNP 6675 Child/Adolescent Psych Adult Mix Pt.2

MD or NP preference

Do you prefer an MD or NP as preceptor?

Medical Doctor

Nurse Practitioner

Other (Therapist/Social worker)

Start Date for class

When will your class begin? For example, at Walden the Winter session for 2021 begins Nov. 29th, 2021

MM

DD

YYYY

Location

Where are you located?

Houston

Other

I am open to doing part or all of my rotation as a tele-medicine experience during Covid-19

Many Universities are allowing 100% tele-medicine during Covid

Yes

No, I want to avoid tele-medicine learning

I have not decided but I am open to the possibility

Acknowledgment

I understand the following: ACE is a professional consulting service. Consultations are 100% free -- however, any programs I choose to join later would carry an expense of $10 or $12.50 per clinical hour depending on the specialty and location (NU students exempted)

Yes