Preliminary Approval Form

Practicum/Internship Application

Welcome to the first step of your counseling journey! Please complete the application below, which is the first step in determining if our site might be a good fit for your internship program and career aspirations. The preliminary information gathered below helps to ensure alignment between your expectations and our site's capabilities, as well as necessary information to ensure our site meets your graduate programs esteemed standards.
Name*

First NameLast Name
Email*
Please use your personal or school email,.
Phone Number*
Please enter a valid phone number.
Anticipated Internship Start Date*

MonthDayYear
Date
Upload your most recent CV/Resume.*

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Upload your cover letter. *

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Graduate Program Details

To ensure approval as a potential internship site, please provide the details about your graduate program. The representative of your school can be:
- Field Placement Coordinator/ Internship Program Coordinator
- Director of Internship
- Director of your graduate program
- Professor for your practicum or internship course(s)
Once you submit this form, it will be sent to that individual for them to also verify that the information submitted is accurate.
What school do you currently attend?*
Which Program are you completing?*

Counseling PsychologyClinical Mental Health CounselingMarriage and Family TherapySocial WorkOther
Name and Title of Your School Representative*
Email of Your School Representative*
example@example.com
Anticipated Graduation Date*

MonthDayYear
Date
Please upload a copy of your practicum or internship syllabus and/or your field placement handbook for your program. *

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Please indicate the number of hours required for each breakdown type. *

	Per Semester/Quarter	Total Required
Direct Hours
Indirect Hours
Group Hours
Relational Hours (Ex. Couples or Family)

Does your graduate program require GROUP therapy hours?*

YesNo
Does your graduate program require interns to complete all DIRECT hours onsite (not remote)?*

YesNo
Does your graduate program require interns to complete all INDIRECT hours onsite (not remote)?*

YesNo
We require a commitment of at least one year to the internship program. Do you intend to complete your requirements for all of your required field training for your program at our site?*

YesNoI've already completed one or more semesters/terms for my program
Are you permitted to continue your practicum/internship in between semesters (i.e. Summer or between Fall and Spring semesters)?*

YesNoOnly with prior approvalOther
Please indicate your preferred client population. Please note, as a part of the internship experience, you may be assigned clients outside of your preferred population as part of the training experience.*

Children (5-11)Adolescents (12-17)Young Adults (18-30)Adults (18+)Couples TherapyFamily Therapy
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Practicum/Internship Application