Counseling Program Admissions Coordinator

COUNSELING PROGRAM ADMISSIONS COORDINATOR

COUNSELING AND PROFESSIONAL STUDIES

SOUTHERN ARKANSAS UNIVERSITY

CROSS HALL

100 EAST UNIVERSITY AVE.

MAGNOLIA, AR 71754

Application for admission to:

___ Master’s program in Clinical Mental Health Counseling

___ Master’s program in School Counseling

___ Master’s program in Student Affairs and College Counseling

Please print or type:

Name:_________________________________________________________

(Last) (First) (Middle)

Present Address:_________________________________________________

______________________________________________________________

Permanent Address:______________________________________________

______________________________________________________________

Social Security #:______________________ Phone:____________________

U.S. Citizen? ___Yes ___No

Email Address:__________________________________________________

EDUCATION AND TRAINING:

Name of College/University Period of Study Major/Minor Degree Awarded

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

SUPPLEMENTARY EDUCATION: (In-service training, institutes, short courses, etc.)

Subject Sponsored by Dates of Study

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

EMPLOYMENT: (Include all substantial work experience)

Name/Address of Employer Job Title/Duties Dates of Employment Reason for Leaving

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

VOLUNTEER EXPERIENCES: (Include all volunteer experience relevant to the counseling profession)

Volunteer Activity Agency/University/etc. Dates

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

HONORS, AWARDS, AND DISTINCTIONS:

MEMBERSHIP IN PROFESSIONAL ASSOCIATIONS:

PROFESSIONAL CERTIFICATION OR LICENSE HELD:

REFERENCES: List persons, other than relatives or friends, who have knowledge of your background, experience, abilities, qualifications, etc. Put an asterisk next to the references you have included in your Counseling Program Application (at least two of these three references must be able to discuss your academic record/potential unless applicant has been out of school for a period longer than five years). Include their letters with this application.

Name Address Occupation ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

PLEASE ANSWER THE FOLLOWING ESSAY QUESTIONS:

You will note that the essay is divided into seven basic sections. Complete each item so that you believe the intent of that item has been adequately covered. We are looking for no more than 100 words, or two to three paragraphs, for each item.

Item 1: The reasons I’m pursuing a career in counseling are:

Item 2: Why have you chosen the specific master's program you selected?

Item 3: Describe the events that have had significance to your development in your early years, noting any special activities or organizations in which you have been involved.

Item 4: Consider what makes your desired profession relevant to you and what assets you posses that will contribute to your success as a professional.

Item 5: What are your values as they relate to the counseling profession? How do these values guide you in assisting others? List specific examples.

Item 6: My commitment to professional development is best expressed and demonstrated by:

Item 7: Please add any additional information you would like the Counseling Admissions Committee to consider as part of your application to the program.

ALL APPLICANTS COMPLETE AND SIGN:

If initial screening is favorable, would you be available for a personal interview at Southern Arkansas University? ______Yes ______No

If accepted, I plan to attend: _____part-time _____full-time

I plan to begin my studies: Fall ______ Spring______ Summer______

(year) (year) (year)

I understand as a student in the counseling program, I will be encouraged to enter personal counseling as part of my personal and professional growth. I am aware that being a student in a professional counseling program, I will be engaging in life changing experiences. As such, I am aware that I will be expected to be self-reflective and open to new experiences in each of my courses and field experiences, and the faculty will meet on a regular basis to review my personal, academic, and professional growth in the program. As a result I am aware that I may be required to engage in, and provide appropriate documentation of, professional counseling or additional supervision services. I am aware that the department has a student handbook, which describes my rights and responsibilities for the duration of my experience in the program.

_____________________________________(Date)____________ (Signature of Applicant)

I also affirm that the information which I have provided on this application form and all other admission material is complete, accurate, and true.

_____________________________________(Date)____________ (Signature of Applicant)