16%
BHWD (MIP) Intern Pre/Post Evaluation Survey
Questions marked with a
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are required
Directions:
There are no right or wrong answers on this survey. This survey will be used to help assess and understand how this mentored internship contributed to the development of your knowledge and skills. Information from this survey will only be reported in aggregate. Your individual responses will be kept confidential.
Date of survey completion
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Year
2023
2024
2025
Intern Contact Information
First Name
Last Name
Phone
Personal (non-work/non-school) Email Address
Alternate Email Address
Internship Start Date
Month
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Year
2022
2023
2024
Internship End Date
(If you do not know your exact internship end date yet, please give your best estimate of when you will complete your internship.)
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
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Year
2023
2024
Education Institution
Intern Education Level
High school
Community College
Undergraduate
Masters
Doctorate
Post-Doc
Other
Grantee Agency Name
-- Select --
Adventist Health Clear Lake
Aldea Inc.
AltaMed Health Services
Another Choice, Another Chance
Archway Recovery Services, Inc.
Bartz-Altadonna Community Health Center
Caminar
Casa Pacifica Centers for Children & Families
Center Point, Inc.
Children's Home of Stockton
Chinatown Service Center
Citrus Counseling Services, Inc.
CommuniCare Health Centers
Community Solutions for Children, Families and Individuals
Compatior, Inc.
Comprehensive Community Health Centers
Council on Alcoholism and Drug Abuse
Dignity Community Care dba California Hospital Medical Center
Dual Diagnosis dba Health Care Integrated Services Inc.
El Dorado County Community Health Center
El Hogar Community Services Inc.
Episcopal Community Services of San Francisco
Family Alliance for Counseling Tools & Resolution
Family Dynamics Resource Center
Florence Crittenton Services of Orange County; DBA Crittenton Services for Children & Families
Foothill Family Service
Fred Brown Recovery Services
Fresno Family Counseling Center/California State University, Fresno Foundation
Gardner Family Health Network, dba Gardner Health Services (Specialty Behavioral Health Division)
Gateways Hospital and Mental Health Center
Glenn County Behavioral Health
Grandma's House of Hope
Greater Hope Foundation for Children, Inc. (DBA: A Greater Hope)
HealthRIGHT 360
Health Service Alliance
HEPPAC
Helpline Youth Counseling, Inc.
Higher Ground Youth and Family Services
Hill Country Community Clinic
Humboldt County Department of Health and Human Services, Behavioral Health
Imperial County Behavioral Health Services
Insights Counseling Group
Janus of Santa Cruz
Inner-Tribal Treatment
KidsFirst Child Abuse Prevention Council of Placer County
Kings View
Korean Community Center of the East Bay
Korean Community Services Inc. (KCS)
La Clinica de La Raza, Inc.
LAGS Recovery Centers, Inc.
LifeLong Medical Care
Los Angeles Centers for Alcohol and Drug Abuse
Mathiesen Memorial Health Clinic
Mendocino County Behavioral Health and Recovery Services
Merced County Behavioral Health and Recovery Services
Momentum for Health
Monterey County Health Department, Behavioral Health Bureau
Norooz Clinic Foundation
North County Health Project, Inc., d.b.a. TrueCare
Open Door Community Health Centers
PathPoint
Penny Lane Centers
Petaluma Health Center
Phoenix Houses of Los Angeles, Inc.
Phoenix House Orange County, Inc.
Portia Bell Hume Behavioral Health and Training Center
Quality Group Homes DBA Quality Counseling Center
Rancho San Antonio Boys Home, Inc.
Rebekah Children's Services
Redwood Community Services Inc.
Remarkable Marriage and Family Institute dba Remarkable Services
Riverside University Health System - Behavioral Health
Samuel Dixon Family Health Center, Inc.
Sacramento Youth Center
San Diego Center for Children
San Diego Freedom Ranch, Inc.
San Mateo County Health Foundation
Seneca Family of Agencies
Shasta Community Health Center
Sharp HealthCare Foundation
Sierra Meadows Foundation
Social Model Recovery Systems, Inc.
St. John's Community Health
St. Joseph Center
Stanford Youth Solutions
Sycamores
Tarzana Treatment Centers, Inc.
The AMAAD Institute
The Anti-Recidivism Coalition (ARC)
The Center for Sexuality & Gender Diversity
The DreamPower Foundation
The Guidance Center
The Happier Life Project
The Purpose of Recovery
The Regents of the University of California, Davis
The Village Family Services
Tulare County Health and Human Services Agency, Mental Health Branch
United Indian Health Services, Inc.
Valley Health Associates
Venice Family Clinic
Ventura County Behavioral Health Department/County of Ventura
Via Care Community Health Center
Victor Community Support Services, Inc.
Vista Hill Foundation
Vista Hill ParentCare Central
Wesley Health Centers (JWCH)
WestCoast Children's Clinic
Whole Systems Learning
Organization Unique ID
(Please ask the MIP Coordinator for this information. It should be formatted as MIPXXXX.)
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