Counseling Center

Please print this form and return to Don Mullison, Ph.D., Practicum Coordinator. Feel free to write on the back.

SIU‑C COUNSELING CENTER
ADVANCED PRACTICUM
APPLICATION

NAME: ____________________________________________

TODAY'S DATE: ____________________________________

DEPT/PROGRAM: ___________________________________

YEAR IN PROGRAM: _________________________________

1. For what semester/year are you applying to complete an advanced practicum?

_________________________________________________________________________________

2. What are your training goals for this experience? (This may include special client populations with which you would like to gain supervised experience, or specific therapist skills you would like to focus on in your supervision.)

_________________________________________________________________________________

3. Have you discussed your interest in this practicum with any potential supervisors in this agency?

Yes ______ No ______

If so, with whom? ____________________________________________________________________

4. Is there any other information that you think is important for us to know in evaluating your application?
Yes ______ No ______

If so, what ? ____________________________________________________________________

__________________________________________________________________________________

Thank you for your cooperation in completing this form. It should be returned to the Practicum Coordinator who will review it, and in consultation with the Counseling Center training staff and your faculty, will make a decision regarding our ability to provide the training experience you are seeking.

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