Western Kentucky University Department of Counseling and Student Affairs School Counseling Internship Application Form

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Marianna Allison
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1 Western Kentucky University Department of Counseling and Student Affairs School Counseling Internship Application Form SECTION I: Internship Applicant Information Date: Student Name: Address: City: State: Zip: Home Telephone: Cell Phone: WKU What semester are you applying for? Fall Spring Year? Note the month and date of the Internship Orientation you attended. Note the semester, year and grade for the following courses. All courses must have a grade B or better to apply for Internship CNS 550 Introduction to Counseling Semester Year Grade CNS 554 Group Counseling Semester Year Grade CNS 555 Social and Cultural Diversity Semester Year Grade CNS 558 Counseling Theories Semester Year Grade CNS 559 Techniques of Counseling Semester Year Grade CNS Practicum in School Counseling Semester Year Grade CNS 595 Internship I Semester Year Grade Upon enrolling in Internship, I agree to the following: a. I have completed the Internship Orientation; have read and understood the Practicum and Internship Manual; and have a Practicum and Internship Informed Consent Form signed and on file for the current semester. b. I agree to adhere to the policies, rules, standards and practices set forth by the Department of Counseling and Student Affairs for the Internship experience that are expected of me as outlined in the School Counseling Practicum and Internship Manual. c. I am aware of the American Counseling Association (ACA) Code of Ethics and I will behave according to these Standards. Any breach of these ethics or any unethical behavior on my part will result in my removal from Internship and a failing grade, and documentation of such behavior will become part of my permanent record. d. I will adhere to the administrative policies, rules, standards, and practices of the Internship site. e. I am responsible for keeping my Internship Supervisor(s) informed regarding my Internship experiences. f. I will not be issued a passing grade in Internship unless I demonstrate the specified minimal level of counseling skill, knowledge, and competence and complete course

Note the semester, year and grade for the following courses.

2 requirements as required. That is, I must earn at least a B in Internship I in order to proceed into Internship II and graduate. g. I understand that an assessment of my progress throughout the program (including Practicum and Internship) will be conducted. This assessment will include consideration of my academic performance, professional development, and personal development. h. I understand that I should video record all of my counseling sessions. I understand that in order for this application to be considered I must submit the following documents with this Internship Application Form by the given due date. I understand that I will not be considered for Internship unless the Internship Application, along with a completed Site Supervisor Information form (Section II) has been submitted in its complete form by the due date. In completed form, scan all of the documents in the order noted below and to the School Counseling Clinical Coordinator Internship Application Form (this document) Copy of unofficial graduate transcript Proof of Professional Membership (i.e., ACA, KCA, ASCA, KSCA, APT, KAPT) Copy of Malpractice Insurance Site Supervisor Information Form and Site Supervisor s vita (if not submitted for Practicum) SECTION II: SITE SUPERVISOR INFORMATION FORM The following section should be completed by the proposed Site Supervisor after reading the Counseling Practicum Responsibilities Page. The school counselorin-training must electronically send this document to the potential Site Supervisor. The Site Supervisor will complete this entire document (including the above section) on the computer, re-save it in the same format, and then it back to the school counselor-in-training. Proposed Site Supervisor Information a. License and Professional Credentials All Internship sites are approved based on several criteria. One requirement is related to on-site supervision. Site Supervisors, for example, must be appropriately experienced, credentialed, and licensed. For example, a minimum of a Master s degree in School Counseling including certification as a School Counselor. Name of Site Supervisor: Name of School: Address of School Site: Phone of School: Site Supervisor Certification: Date certification issued: University Attended for School Counseling program: Date received School Counseling master s degree:

This assessment will include consideration of my academic performance, professional development, and personal development. h. I understand that I should video record all of my counseling sessions.

3 Other licenses and/or credentials: b. Clinical and Professional Experience All School Counseling Site Supervisors are required to have a minimum of two (2) years of pertinent professional experience as a certified School Counselor. Please provide a brief description of your professional and certified experiences in 3 to 5 sentences: Please provide a brief description of your relevant professional training in 3 to 5 sentences: c. Site Information The Department of Counseling and Student Affairs has identified criteria for potential Practicum sites that we believe are essential. Please provide a thorough response to each of the following responses: Mental health counseling services (individual and small group counseling) must be provided at the site. Please briefly describe a description of site and what services are offered to students in your school. Please describe the typical students in your school. What expectations do you have of the school counselor-in-training? Video-taping of clients is a requirement of all school counseling students-intraining. Please check to verify that video taping of counseling sessions is allowed at this site and may be shared with the Faculty Supervisor/Instructor and group supervision class. d. I have attended or viewed the On-line Site Supervision Orientation provided by the Department of Counseling and Student Affairs on the following date: By signing below, I agree that I have read, understood and agree to the above-mentioned

Please provide a brief description of your professional and certified experiences in 3 to 5 sentences: Please provide a brief description of your relevant professional training in 3 to 5 sentences: c.

4 terms. Digital Signature Here! ***I have no idea why this space is here??? I can t get it to delete

5 Internship Student Date Site Supervisor Date School Counseling Clinical Coordinator Date Instructions for completing this form: 1. Save this form to your computer. Save with the file name: Your Last Name + Your First Initial + InternApp + MonthYear. For example, BrattonIInternApp Electronically send the entire document to your potential Site Supervisor. Ask the Site Supervisor to complete the form on the computer, re-save it in the same format, and then it back to you. Be sure that the Site Supervisor includes an electronic copy of his/her vita with this form. 3. Be sure to include all information for processing of your Internship application.

Electronically send the entire document to your potential Site Supervisor.

CMHC/MFT Intern Contract Rev. 08/26/12 1

CMHC/MFT Intern Contract Rev. 08/26/12 1 Western Kentucky University Department of Counseling and Student Affairs Clinical Mental Health Counseling; Marriage and Family Therapy Internship Site and Supervision