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CLINICAL MENTAL HEALTH COUNSELING PROGRAM PRACTICUM/INTERNSHIP STUDENT AND SITE INFORMATION FORM

Notification of finding a site must be submitted by MAY 1 for a practicum/internship starting during Fall semester; no later than DECEMBER 1 for a practicum/internship starting during Spring semester; and no later than APRIL 1 for an internship starting during the Summer semester. These deadlines are non-negotiable. Failure to submit this form by the deadlines indicated above may result in a student being unable to enter the course. To fill out this form you must attest that you will complete and retain copies of the following BY THE FIRST DAY OF CLASS: 1) Practicum Intent Form with Developmental Statement 2) Practicum/Internship Field Agreement 3) Supervisor Qualification Form 4) CT Initial Application Sent to Board 5) Proof of Insurance and 6) Proof of Current CT Status.

  • 1 Current: Step 1 of 2
  • 2 Step 2 of 2
  • 3 Complete

Student Information

  • Note: You will have to submit this form THREE times (once for 592, once for 596A, and once for 596B) during your course of study.  Plus if you change sites during the semester you will have to resubmit this form with your new site information.

Site Information