Currently on website 1/31/18: Clone of Form 1000 - Application for Practicum and Internship

Form 1000: Application for Practicum and Internship
This application, when approved, reserves a space for you in the 8-hour semester practicum/internship sequence. You will only be notified by approver if there are issues or concerns.

In order to graduate Clinical Mental Health and Rehabilitation Counseling students need:

CPS 7660 or CPS 7663 (fall term).

CPS 7680 or CPS 7683 (spring and summer term).

This course sequence is taken consecutively. Courses in the sequence cannot be taken in the same semester.
Program of Study:
Entry Semester
Year
Expected Graduation Semester
Year
Semester you plan to begin practicum:
Have you secured a practicum site?*

YesNo
Site Secured*
Contact Personnel *

First NameLast Name
Personnel E-mail*
Student Information:
E-mail*
Full Name

First NameLast Name
Panther ID*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Daytime Phone #*

Area CodePhone Number
Evening Phone #

Area CodePhone Number
Date Applied:

MonthDayYear
Date
Please verify that you are human*
Should be Empty: