Application Form for the

InTouch Crisis Hotline Training Program
__________________________________________________________________________ 

Applying to the InTouch Training Program is simple! Just print out this application form, fill in the requested information, and return the completed form in person or by mail to 
 

University of Illinois at Chicago Counseling Center 
Suite 2010, Student Services Building M/C 333 
1200 West Harrison 
Chicago, IL 60607  
Attention: InTouch Hotline Application

The program coordinator will contact you in order to schedule the in-person interview. 

If you have any questions or concerns regarding the application procedure, please contact Andrew Sia or Dr. Anmol Satiani, Co-Coordinators of InTouch Hotline.

Semester you wish to take the course:

     _____ Spring Semester, year __________

     _____ Fall Semester, year __________ 

Name:              _______________________________________________________________ 
    
Street 
Address:            _______________________________________________________________  

City:                   ________________________________________    Zip Code:____________  

Home Phone:           _____________________  

E-mail:                       _____________________ 

Times you can best be reached at home_____________________________    

Sex:  _____Male     _____Female 

Birthdate:___________________

University Identification Number:____________________  (This is a 9-digit number in blue on your i-card) 

Academic Status: _____Freshman     _____Sophomore     _____Junior     _____Senior     _____Graduate 

Major:_____________________________     

Number of credits you are taking this semester:____________  

Current GPA:________      Expected graduation: __________(month)     _____(year)  

Do you work? _____No     _____Yes      If yes: How many hours per week?_______ 

May we contact you at work? _____No     _____Yes      If so, work phone number:____________________________  

1) Why do you want to be a campus paraprofessional? 
 
 
 
 
 

2) What skills could you contribute to effectively serve as a campus paraprofessional? 
 
 
 
 
 

3) What experiences have you had (volunteer or otherwise) that demonstrate your concern for people and your ability to communicate? Please include dates. 
 
 
 
 
 

4) What other academic or extracurricular commitments do you have or plan to have the semester you plan to do your paraprofessional volunteer work (the semester after you take the course)? 
 
 
 
 
 

5) How would being a paraprofessional fit into your career or personal goals? 
 
 
 
 
 

6) How did you find out about the UIC Campus Paraprofessional Program? 
 
 
 
 
 

7) Please provide the name, phone number and relationship of two references who can speak about your qualifications for this program (i.e., professor, employer, clergy, friend, or family member). 

Reference 1:   _________________________________________________________________________

Reference 2:   _________________________________________________________________________

8) Are you willing to make a time commitment of 5-6 hours per week the semester you do your volunteer work? 

Yes No 

9) Is there anything else you would like us to know in considering your application? 
 
 
 
 
 
 

To help us avoid potential dual relationships or conflicting roles, if you would like to be considered to work at the InTouch Hotline, please also answer the following questions. This information will not be used to look up treatment records or to select/ eliminate applicants, but rather to help us in assigning tasks to our current staff members. 

Are you currently in psychotherapy or counseling at the UIC Counseling Center? _____Yes     _____No 

Have you ever been in therapy in the past at the UIC Counseling Center? _____Yes     _____No 

 I affirm that all information submitted in this application is true. I understand that all information submitted will be considered and treated as confidential. 

Signature______________________________________ Date________________________