Counseling Practicum Application

I am applying for FALL ______Date submitted: ______

Contact Information

Name ______Student #______

Address______

______

Telephone #’s:

Home ______Cell ______Work______

Program Status

Accepted as:

______Part-time (3 Yr.) ______Full-time (2 Yr.)______Other

Advisor: ______

Provide information on the following courses that must be completed prior to counseling practicum, unless you receive an exception:

/ Coursework / Grade
REHB 600: Introduction to Rehabilitation
REHB 610: Medical Aspects of Rehabilitation
REHB 680: Research Seminar
COUN 501: Counseling Theories & Techniques I
REHB 612: Disability Across the Lifespan
REHB 620: Career Development & Job Placement
COUN 505: Theories of Human Appraisal
COUN 606: Counseling Theories & Techniques II
COUN 634: Cultural Issues in Counseling
COUN 645: Couples and Family Counseling
COUN 664: Ethical Issues in Counseling
COUN 640: Addictions Counseling

If you are in the 2-year program, you will also enroll in the following classes:

  • COUN 665 Diagnosis and Treatment Planning
  • COUN 668Crisis, Trauma and Grief
  • REHB 624Rehabilitation Client Services

If you are enrolled in the 3-year program, you will also enroll in the following class:

  • COUN 668Crisis, Trauma and Grief

Employment

Are you a (Graduate Assistant (GA)? _____

Are you currently employed?YesNo

If yes, where?

If you will be employed during your counseling practicum experience, keep in mind that most sites will NOT schedule your hours around your employment. Your priority in the program is to complete your counseling practicum hours.

Are you currently employed at a site in which you would like to complete the practicum experience? Yes No

Please provide information on the site’s suitability as a counseling practicum site. You will be required to engage in new learning related to development of your counseling skills on this site.

Employer

Job Title

Job Description

Site Supervisor

Name

Telephone #

Email

Credentials

Sites Which Interest You (please complete ALL information below)

Name AND Address / Supervisor / Telephone/email
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2.
3.

Practicum sites not on the list or are at your place of employment must be approved well in advance by the clinical coordinator (see clinical experience manual/coordinator for requirements).

Attach the following:

  1. Additional information regarding extenuating circumstances and/or accommodations (approved by WVU Office of Accessibility Services) and special interests.
  2. Updated Resume
  3. Self-Inventory for practicum site selection

(Do Not Write In Block)

Approved:______Not Approved: ______

Comments:______

______

______

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