UNIVERSITY OF WASHINGTON COUNSELING CENTER

Transcription

1 1 UNIVERSITY OF WASHINGTON COUNSELING CENTER Practicum Counselor Application Name_Date Current Doctoral Program: Highest Degree Earned: Academic Institution in Which Highest Degree Earned: Field in Which Highest Degree Earned: Year in Which Highest Degree Earned: Home Address: Telephone: (Mobile) (Home) (Work) Address: What is the contact information for your current Director of Clinical Training in your doctoral program? Name: Mailing Address: Phone Number:

2 2 Previous Practicum and Counseling Experience*** Placement/Site: Name, Telephone Number, and Address of Clinical Supervisor: Dates of Service at Site (mm/dd/year began and mm/dd/year ended): Number of Direct Client Contact Hours and Estimated Number of Total Hours at Site: Number of Clients Seen at this Site: Age/Population of Clients Seen at this Site: Type of Clinical Contact/Treatment Modality (i.e. individual therapy, group therapy, assessment, etc.): individual therapy group therapy couples therapy assessment Placement/Site: Name, Telephone Number, and Address of Clinical Supervisor: Dates of Service at Site (mm/dd/year began and mm/dd/year ended): Number of Direct Client Contact Hours and Estimated Number of Total Hours at Site: Number of Clients Seen at this Site:

3 3 Age/Population of Clients Seen at this Site: Type of Clinical Contact/Treatment Modality (i.e. individual therapy, group therapy, assessment, etc.): individual therapy group therapy couples therapy assessment Placement/Site: Name, Telephone Number, and Address of Clinical Supervisor: Dates of Service at Site (mm/dd/year began and mm/dd/year ended): Number of Direct Client Contact Hours and Estimated Number of Total Hours at Site: Number of Clients Seen at this Site: Age/Population of Clients Seen at this Site: Type of Clinical Contact/Treatment Modality (i.e. individual therapy, group therapy, assessment, etc.): individual therapy group therapy couples therapy assessment ***If you need more room or additional space, please attach additional page to the application.

4 4 Please Check All Courses Completed Which Have Addressed These Areas: Counseling theories Counseling skills / interventions Psychopathology Clinical interviewing Practicum/Field Placement Multicultural/Cross-cultural Counseling Have you audio/videotaped/recorded your clinical work? audio video Have you been audio/videotaped/recorded in supervision? audio video Please answer the following questions using the space provided. If needed, you may use a separate sheet of paper. 1. What psychological theories do you use in your therapy with clients? 2. What feedback have you received in previous practicum about your strengths and target areas of improvement regarding: Counseling Skills Strengths: Areas for Improvement

5 5 Understanding Client Dynamics Strengths: Areas for Improvement: Use of Supervision Strengths: Areas for Improvement: 3. What specific areas would you like to concentrate on during your practicum experience? 4. How do you see this practicum experience at our University Counseling Center fitting into your educational goals and into your career aspirations?

6 6 Send all application materials to: Agnes Kwong, Ph.D. Practicum Training Coordinator University of Washington Counseling Center 401 Schmitz Hall, Box Seattle, WA Phone: (206) FAX: (206) The UW Counseling Center accepts applications starting January 1 and will be interviewing applicants from the end of February to early March for the following academic year. Center Director: Ellen Taylor, Ph.D. University of Washington Counseling Center 401 Schmitz Hall, Box Seattle, WA Phone: (206) FAX: (206)