Counseling Center Application Form APPLICATION FOR (Check all that apply):* Masters Level Practicum Masters Level Graduate Assistantship Masters Level Graduate Internship Doctoral Level Practicum Doctoral Level Graduate Assistantship N/A Part I: Background InformationName:* First Last Date:* Local Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 PsychologyMental Health CounselingHours 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
