Graduate Certificate Departmental Application

Transcription

1 Continuing Education Program Portland OR Graduate Certificate Departmental Application Name SSN - - Last First MI Address Street City State Zip Telephone Home Daytime (if different) Message Date of birth / / month day year Addictions Counseling Couples, Marriage and Family Counseling Term applying for: Year Fall Winter Spring Summer Ethnicity (Optional): Asian Black, non-hispanic Caucasian Hispanic Other Native American Non-resident International Language Ability: Do you speak a language other than English yes no If yes, what language do you speak What is your ability level (circle one): Basic conversation Fluent conversation Fluent reading, writing, conversation 1. Education: School attended City, State Degree awarded/ # of credits received GPA Date received

2 Kathy Lovrien - Graduate Certificates Continuing Education Program Portland OR List below any license(s) you have had issue to you: 3. Employment information Place of empolyment Address Street City State Zip Supervisor name Number Past experience in human services: # of years working or volunteering in human services. Please describe these experiences (you may attach another sheet of paper if more space is needed). Name of organization Job responsibilities: Name of organization Job responsibilities: 4. Attach the following: 1. Personal Statement (see attached) 2. Evaluations of Applicant for Graduate Certificate (see attached) 3. Resume ***It is the applicant s responsibility to have official transcripts sent directly to Continuing Education/ by the due date. The application cannot be reviewed until all materials are received.***

3 Continuing Education Portland OR Graduate Certificate Application Personal Statement Name of Applicant: SSN / / Last First MI Personal Statement Describe your professional experience and academic background and identify why you believe you would be an effective professional Addictions Counselor or a Couples, Marriage and Family Counselor. Describe how this Certificate Program aligns with your professional goals. **SHOULD NOT BE MORE THAN 500 WORDS TYPED** Portland State University

4 Counselor Education Program Portland OR Graduate Certificate Program - Evaluation of Applicant Name of applicant SSN / / Addictions Counseling Couples, Marriage, & Family Counseling Term/ Year applying for: Fall Winter Spring Summer Name of person completing this form Organization Position Address Phone Street City State Zip Daytime Relation to Applicant Length of time known Thank you for taking the time to complete this evaluation for the prospective student interested in our program. This information will be used in making decisions on admission. Be sure to complete both 1 and Please check one box in each row. Poor Academic potential Dependability Ability to express ideas orally Ability to work with others Breadth of general knowledge Professional success thus far Below average Satisfactory Good Excellent No basis for judgment 2. Please attach your comments regarding your perception of the individual s strengths and potential as an Addictions Counselor or Couples, Marriage and Family Counselor. Signature Date PLEASE RETURN IN A SEALED ENVELOPE TO THE APPLICANT. THE APPLICANT WILL NOT BE CONSIDERED FOR ADMISSION WITHOUT THIS FORM.

5 Kathy Lovrien - Graduate Certificates Counselor Education Program Portland OR Graduate Certificate Program - Evaluation of Applicant Name of applicant SSN / / Addictions Counseling Couples, Marriage, & Family Counseling Term/ Year applying for: Fall Winter Spring Summer Name of person completing this form Organization Position Address Phone Street City State Zip Daytime Relation to applicant Length of time known Thank you for taking the time to complete this evaluation for the prospective student interested in our program. This information will be used in making decisions on admission. Be sure to complete both 1 and Please check one box in each row. Poor Academic potential Dependability Ability to express ideas orally Ability to work with others Breadth of general knowledge Professional success thus far Below average Satisfactory Good Excellent No basis for judgment 2. Please attach your comments regarding your perception of the individual s strengths and potential as an Addictions Counselor. Signature Date PLEASE RETURN IN A SEALED ENVELOPE TO THE APPLICANT. THE APPLICANT WILL NOT BE CONSIDERED FOR ADMISSION WITHOUT THIS FORM.