Fillable UT Tyler Student Counseling Center (University of Texas at Tyler)

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UT Tyler Student Counseling Center (University of Texas at Tyler)

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UT Tyler Student Counseling Center
APPLICATION FOR INTERN/PRACTICUM TRAINING
NAME: ___________________________________________________________________________
ADDRESS: ________________________________________________________________________
PHONE NUMBERS: Home: ________________________ Work: __________________________
Cell: _________________________ Other: __________________________
EMAIL Address: ____________________________________________________________________
PROGRAM NAME: CMHC (MA) ___________ Clinical (MS)______________
PREVIOUS INTERN/PRACTICUM EXPERIENCE(S)
Site: ____________________________________________ Hours: _____________________
Population: _________________________________ Supervisor: _______________________
Site: ____________________________________________ Hours: _____________________
Population: _________________________________ Supervisor: _______________________
RELEVANT CLINICAL WORK EXPERIENCE (if applicable):
Additional Questions
1. What experience/training have you had with regards to working with diverse
populations?
2. Individual Therapy Goals -- What are some of your areas of growth as an individual
therapist and what are some goals you have in this area?
3. What experiences and training have you had, to date, related to group theory, group
process, and group leadership issues?
4. What are your goals after graduation?
• Submit the completed application with resume to Les Glover, Assistant Director of Clinic
Services: lglover@uttyler.edu
• All Interns/Practicum students accepted will be required to go through training prior to
the semester beginning.
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UT Tyler Student Counseling Center (University of Texas at Tyler)

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Completed 2 February 2021

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