Counseling - Application for Practicum

To qualify for Practicum experience at LMU, a counseling degree candidate must fulfill the following requirements as outlined in the Counseling Program Handbook:

A. Complete 18 hours of Counseling Graduate Study,

B. Complete CG 631 – Group Counseling,

C. Be fully admitted through the Graduate Education office to Degree Candidacy in the CounselingProgram,

D. Maintain Active Professional Liability Insurance (student rate available through ACA),

E. Complete this Application to Practicum form.

Please fill out this form and turn in to Dr. Shelley Salter, Practicum and Internship Coordinator, by noon on May 1.

Application is for (select one)

Mental Health Counseling Practicum Placement School Counseling Practicum Placement

Campus

Cedar Bluff Harrogate

Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail

Phone Number

Area Code Phone Number

Where would you like to complete your Practicum if known? (If not, leave blank)

In LMU Counseling Program, generally, students arrange a Field Placement site. Students are encouraged to work with Faculty Advisors or the Practicum and Internship Coordinator in this process. For all Practicum Placement Sites, a site supervisor must be identified who has:

Masters Degree in Counseling or the equivalent
Three years of experience and appropriate licensure in the setting in which you will be serving.
Willingness to provide face-to-face, individual supervision each week.

Please provide the following information about the proposed site-supervisor if known (if not, leave blank).

Supervisor’s Name:

Agency or School:

Address

Phone Number

Area Code Phone Number

E-mail

In the space below, list the graduate-level Counseling courses you have taken at LMU (including any that you are registered to complete in the Summer). A minimum of 18 hours of Graduate Counseling Coursework must be completed prior to beginning Practicum.

Please list Course Number and Name, Semester Taken, and Grade Earned.

In what state do you plan to be licensed as a counselor?

When do you anticipate receiving Master’s degree?

When do you plan to take Comprehensive Exams?

How will this Practicum site facilitate your gaining experience with diverse individuals? In answering this question, please consider the totality of the definition of diversity as follows: Differences among groups of people and individuals based on ethnicity, race, socioeconomic status, gender, exceptionalities, language, religion, sexual orientation and geographical area. (Provide answer here in no less than 300 words.)

Thank you for completing your application. Counseling Program Faculty will review all applications in the month of May. You will receive an email informing the status of your application by noon on the first Saturday in June.

-Shelley Salter, PhD, NCC

Counseling Program Practicum and Internship Coordinator

Counseling – Application for Practicum