Practicum Application Form

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Practicum Application Form

Applicant Information

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone Number:

Email Address:

Semester(s) applying for:

Current School:

Current Program:

Year in Program:

GPA in Program:

Direct Hours:

Indirect Hours:

For your current program, how many direct and indirect hours are you required to complete?

Have you ever held a position at Blinn College?

Previous Practicum and Counseling Experience

Practicum Site:

Direct Contact Clients Hours:

Primary Supervisor:

Specific areas of interest and/or specialization:

Have you ever been suspended, terminated, or asked to resign by a training program or site?

What interests you about counseling work within a university setting?

What have you learned about yourself in graduate school? What feedback have you received in previous practicum experiences about your strengths and growth areas?

What are your goals/objectives while training at Blinn College’s Mental Health Counseling Office?

What counseling theory or theories do you most closely follow?

How do you maximize your experience in a clinical setting? What qualities characterize effective supervisors?

Required Documentation

Resume:

Letter of Recommendation:

Transcript:

I acknowledge I must submit proof of liability insurance prior to beginning the practicum program with Blinn College District.

Acknowledgement

By typing your name in the spaces below, you are acknowleding the online submission of this application.

Please type your Full Name:

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