Practicum Training Program Application Form : Counseling Center : Texas State University

Date: *

Email: *

Full Name: *

Street Address: *

City: *

State: *

Zip: *

Primary Phone: *

Secondary Phone: (input primary phone again if only one number) *

Education

Undergraduate University: *

Major: *

Degree: *

Undergraduate Year: *

GPA: *

Graduate University: *

Graduate Major: *

Graduate Degree:

Graduate Year:

Current Program: *

Current GPA: *

Current Year in Program: *

Anticipated Graduation Date: *

Other relevant courses/training: (Not Required)

PLEASE ATTACH THE FOLLOWING INFORMATION TO THIS ONLINE FORM (see below):

Prior practica: Attach a sheet describing each practicum: Agency, hours completed, types and Number of clients, range and severity of problems, and name/phone number of supervisor.

Interest in higher education: Write a brief statement about how a practicum in the TxState Counseling Center fits into your graduate program and career plans.

Current Vitae: Attach your current vitae to this online application. You may be asked to provide a hard copy at a later date.

References: Name and phone number for Program Director and of supervisors from prior practica and employment positions.

If you need additional information on the TxState Practicum Program please contact us.

**If you cannot attach the files needed for this application, please send them via postal mail to the following address:

Pam Moore, Ph.D.
Practicum Coordinator
Counseling Center
Texas State University
601 University Drive
San Marcos, Texas 78666

Prior practica (MS Word or PDF format only):

Interest in higher education (MS Word or PDF format only):

Current Vitae (MS Word or PDF format only):

References (MS Word or PDF format only):

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