Practicum Internship Site Application

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Thank you for apply to become an approved practicum/internship site for the University of Central Missouri Counselor Education Program. Please fill out all questions to the best of your ability. If you have any questions, contact Dr. Nancy Forth at nforth@ucmo.edu

Email *

Name of Practicum/Internship Site *

List the name and job title of the person completing this form

Address and phone number of site *

Copy and paste a link to the Practicum Internship Site Website *

Describe the mission and vision statements of the site *

List the services provided at the site *

What kind of recording is allowed? *

Audio recording

video recording

Both

No recording

Other:

Has the site ever applied to the UCM Counseling Program to serve as a site for a Practicum/Internship student? *

Yes

Not sure

If the site was approved in the past, when was the last time a practicum or internship student practiced at the site? Please provide the approximate date or enter NA. *

Does the site provide weekly (1 hour) site supervision to the student? *

Yes

Other:

If the site does provide weekly site supervision, please include all of the following below: Name of the site supervisor, years experience after full license or certification, and licensure or certification number. If the site does not provide supervision, respond NA. *

Does your site charge clients for intern services? *

yes

If the answer to the above is yes, please explain *

How does a student's experience at the site contribute to their learning? *

What else would you like to share about the site?

Send me a copy of my responses.

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