0a. CBCP - Application - Pre-Graduate (Practicum & Externship)

Community-Based Counseling Program(CBCP) Application - Pre-Grad

rev. 1.24
All services are currently on-site and all sites require daytime availability. If you aren't able to provide services in-person and during the day, please do not submit an application at this time.
Application Instructions:

This application will allow you to save and return to it at a later time. Please be sure to select the save button if needed, and you will see a pop-up indicating you have been sent an email link to finish at a later time.

We recommend reviewing the whole application before starting to fill it out. It is often helpful to type your answers in a word document and copy them over when you are ready to complete the application in its entirety. You will need the name and contact information for three(3) references, will answer essay questions, and will also be required to upload the following:
- Program flowchart
- Cover Letter
- Resume
If you have any questions, please reach out to cbcp@nu.edu.

After you submit, a member of our team will reach out to you to schedule an interview within two to three weeks.
Date

MonthDayYear
Date
Practicum Information
Are you currently a JFKSOPSS Student?*

YesNo
What type of degree program are you currently enrolled in?*

Master'sPsyD
What level of practicum are you applying for?*

EthnographicBeginning PracticumAdvanced PracticumExternship
What University/Program are you currently a student of?*

JFKSOPSS at NU - MAMFT (1:1)JFKSOPSS at NU - MAC (Cohort) - MFT onlyJFKSOPSS at NU - MAC (Cohort) - MFT/PCCJFKSOPPS at NU - MSWJFKSOPSS at NU - PsyDOther
What quarter are you applying for practicum?*

Fall Quarter (October - December)Winter Quarter (January - March)Spring Quarter (April - June)Summer Quarter (July - September)
When does your practicum begin?*

MonthDayYear
If you are not a JFKSOPSS student, please identify the College or University you are currently attending.
Are you currently in a practicum(s)?*

YesNo
If yes, with what agency/agencies?
Are you planning to be in another practicum for all or part of the time you are with CBCP?*

NoYes, with this practicum being primaryYes, with my other practicum being primaryYes, unsure of which would be primaryNot sure
Comments
Are you planning for this to be a supplemental/secondary practicum for you?*

YesNo
Are you considering doing supplemental practicum in addition to your primary practicum?*

YesNo
Personal Information
Name*

First NameLast Name
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email Address (use NU email if you have one)*
Academic Information
Education Status*
Student ID # *
Who is your JFKSOPSS Faculty Advisor?*
Who is your JFKSOPSS Program Chair?:*
Who is your University Clinical Training contact?*
Please provide name + email and/or phone number
Who is your University Clinical Training Contact?*
First and last name, title
Email*
example@example.com
Phone Number

Area CodePhone Number
Master's Level Applicants: Are you on track to complete all required pre-practicum classes before the start of your placement? Please note: We may reach out to your practicum coordinator/academic representative to verify your readiness to start practicum.*

YesNoN/A - I'm a PsyD Student
Upload Program Flowchart*

Upload a File
All applicants must upload a copy of their program flowchart or degree program Cancelof
Counseling Psychology Program (select all that apply)*

Marriage and Family TherapyProfessional Clinical CounselorMarriage and Family Therapy - Holistic (includes Depth/Somatic/Expressive Arts/ TranspersonalPsyD EthnographicPsyD Clinical Beginning PracticumPsyD Clinical Advanced PracticumPsyD Externship (Supplemental Practicum)If you don't see your program please list in the other box belowOther
Anticipated Graduation Date*

MonthDayYear
Professional Information
Please describe what you have learned from past clinical/work experiences. Please include your successes and challenges.*
What clinical areas are you interested in pursuing? Are there any areas you would like to specialize in?*
What are your professional goals?*
Please list any languages other than English that you speak/sign:*
Would you be able to conduct therapy in that/those language(s)?*
Essay Questions
1. What has worked well for you with previous managers/supervisors? Please be specific.*
2. What has not work well for you with previous managers/supervisors?*
3. What have former managers/supervisors identified as your areas for growth?*
4. Explain the process of how you have addressed these challenges.*
5. What have former managers/supervisors identified as your strengths? Please provide examples.*
6. What types of clients and/or issues do you feel you will work best with and why?*
7. Please describe your experiences working with marginalized and diverse communities, in community mental health, social justice, or embracing the principles of wellness, recovery, and resiliency. If you have not had these types of experiences, then discuss why you are seeking the kind of experiences this position will offer.*
8. What life changes do you need to make to be able to successfully meet the expectations of this position?*
9. How do you practice self-care in your daily life?*
10. As a part of certain academic programs, students are required to participate in their own personal psychotherapy or spiritual practice. Are you currently participating in psychotherapy/spiritual practice? If yes, please describe how this experience has benefited you.*
References

As part of the application we require a list of references. Please indicate your professional or academic references below. We require that all applicants include at least an email or phone number for each reference.
Reference 1*

First NameLast Name
Reference 1: Relationship*
Reference 1: Phone Number*

Area CodePhone Number
Reference 1: E-mail*
Reference 2*

First NameLast Name
Reference 2: Relationship*
Reference 2: Phone Number*

Area CodePhone Number
Reference 2: Email*
Reference 3*

First NameLast Name
Reference 3: Relationship*
Reference 3: Phone Number*

Area CodePhone Number
Reference 3: Email*
Attachments

Please upload your cover letter and resume/CV.
Upload Cover Letter*

Upload a File

Cancelof
Upload Resume*

Upload a File

Cancelof
If accepted to our program, you will receive an email with a practicum packet that contains infomation and instructions regarding additional requirements that you need to complete prior to the start of practicum. There is nothing you need to do regarding these right now. For your information, they include:
- Proof of Department of Justice (DOJ) Clearance (Live Scan Fingerprinting)
- Proof of Tuberculosis (TB) Testing Clearance (within the last year)
- Proof of Malpractice Insurance ($1M-$3M) - MFT, PCC, ASW
- Proof of completion of Mandated Reporter Training (we will provide this if you have not yet completed)
- Preferences & Availablilty Form
It is the Program's policy that all trainees must be in their own personal psychotherapy no later than the first day of their practicum.

Thank you for applying to the Community-Based Counseling Program in the JFK School of Psychology & Social Sciences at National University. By submitting your application you affirm that all information reported in this application is true and complete, and that you have carefully read our requirements.
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Community-Based Counseling Program(CBCP) Application - Pre-Grad

Practicum Information

Personal Information

Academic Information

Professional Information

Essay Questions

References

Attachments