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Spring 2011 Prac-Intern Form


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Spring 2011 Prac-Intern Form

  1. 1. The Department of Counseling – Community Family Life Center Student Application for Practicum / Internship – Spring 2011 Please submit this application no later than Monday, October 25, 2010. Applicants will be notified via UTSA e-mail of their application status and procedures for registration after the deadline. STUDENT INFORMATION Student Name: Banner ID: Street Address: City: State: Zip Code: Home Phone: Cell Phone: UTSA E-mail: Academic Degree: M.A. Study Program: Course: Catalog of Admittance: 2003-2005 2005-2007 2007-2009 2009-2011 PRACTICUM / INTERNSHIP SITE INFORMATION Affiliated Site Name / Code: Phone: Fax: Specialization: Does this site allow students to audio or videotape for the purpose of supervision? Yes No PREREQUISITES Course Semester Grade Completed Received** Number Name COU 5203 Introduction to Community Counseling A B C D F or or COU 5103 Introduction to School Counseling A B C D F Child and Adolescent Counseling in a Systemic COU 5253 Context (i.e. school track only)* A B C D F COU 5213 Counseling Theories A B C D F COU 5223 Psychological Assessment for Counselors* A B C D F COU 5233 Group Theory and Process A B C D F Counseling Individuals with Behavioral & COU 5243 Emotional Disorders** A B C D F COU 5283 Counseling in Multicultural Setting A B C D F COU 5393 Development of Counseling Skills A B C D F COU 6153 Career Development & Choice* A B C D F EDU 5003 Research Methods in Education * A B C D F EDP 5033 Human Development Across the Life Span* A B C D F *Denotes courses that may be taken concurrently with practicum/internship for the 2007-2009 & 2009-2011 catalogs only. Students in all other catalogs must complete all courses listed above before being eligible to take practicum/internship. **COU 5243 can be taken concurrently with practicum for SCHOOL STUDENTS ONLY IN 2009-2011 catalog. **Please note: Only two “C”s are allowed on your program of study. APPLICANT CERTIFICATION Student Signature Printed Date Application for Practicum/Internship Page 1 Revised: 9/28/10