Counseling Center Application Form

APPLICATION FOR (Check all that apply):*
- Masters Level Practicum
- Masters Level Graduate Assistanship
- Masters Level Graduate Internship
- Doctoral Level Practicum
- Doctoral Level Graduate Assistanship
- N/A
Part I: Background Information
Name:*
First Last
Date:*
Local Address:*
Street Address Address Line 2 City State ZIP Code
Phone Number:*
Alternative Phone Number:
Cub Account Email address:*
Alternative Email address:
Student ID#:*
Previous college(s) attended:*
Dates Attended:*
Degree(s)/Major(s) & GPA(s):*
UCA Graduate Program:*
- Counseling Psychology
- Mental Health Counseling
Hours completed (after this semester):*
Expected Graduation Date:*
Practicum I (date):*
Instructor:*
Location & Agency Supervisor:*
Practicum II (date):*
Instructor:*
Location & Agency Supervisor:*
Doctoral Practicums (date):*
Instructor:*
Location & Agency Supervisor:*
Doctoral Practicums (date):*
Instructor:*
Location & Agency Supervisor:*
Doctoral Practicums (date):*
Instructor:*
Location & Agency Supervisor:*
Part II: Please answer each question with as much detail as necessary:
1 . Describe previous (if any) relevant mental health experience, outside of supervised practicum/graduate training:*
2. Briefly describe your previous practicum experience (if any), highlighting type of setting, client and supervision hours, number and type of clients you worked with, and progress at termination.*
3. What types of clients would you like to work with/learn more about?*
4. What counseling theory/theories do you prefer? Why?*
5. Briefly describe your interest in a position at the Counseling Center (e.g., current client interests, career goals):*
Please Attach a Copy of your Resume/Curriculum Vitae and Provide 3 professional reference(s) from previous employer(s) who are not affiliated with an academic institution.*
Drop files here or

Counseling Center Application Form

Part I: Background Information

Part II: Please answer each question with as much detail as necessary:

Contact Information

Hours

Follow us on Instagram @ucacounselingcenter