Substance Use Disorders Certificate Program Field Experience Registration Intent Form

This form is to be submitted by student no later than October 1 for a Spring semester field experience start, February 1 for a Summer semester field experience start, and no later than March 1 for a Fall semester field experience start. If you miss the deadline the Counseling Department reserves the right to not enroll you in field experience and/or to choose your section for you.

Formal First

Last

Banner ID

Phone

JCU Email

Confirm JCU Email

A confirmation email containing your submission will be sent to this email address.

Statement of pre-requisite coursework for CG 418 or CG 518 Field Experience.

I attest that I will have completed CG 415 or CG 514 AND CG 415 or CG 515; AND will have completed or will be concurrently enrolled in CG 416 or CG 516 AND CG 417 or CG 517.

Reason for why you believe you should be allowed to enroll in CG 418 or CG 518 without the prerequisite coursework:

I will NOT have completed the pre-requisite course work listed above and will provide a reason below for why I believe I should be allowed to enroll in CG 418 or CG 518.

I plan to take CG 418 or CG 518

Please select the term you intend to take CG 418 or CG 518 Field Experience. Note that it will be offered Saturday mornings 9:00-11:40 a.m. concurrent with CG 596A/CG 596B.

I understand that I need to secure a site placement AND submit my placement details using this form, no later than December 1st for Spring, April 1st for Summer, and May 1st for Fall.

Yes

Note that you will need a site with a PCC-S or an LICDC-CS to sign off on your required 220 hours. It must be an agency where the 12 core functions are provided. Indicate below with "Yes" that you understand this.

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Department of Counseling

Substance Use Disorders Certificate Program Field Experience Registration Intent Form

Statement of pre-requisite coursework for CG 418 or CG 518 Field Experience.

I understand that I need to secure a site placement AND submit my placement details using this form, no later than December 1st for Spring, April 1st for Summer, and May 1st for Fall.