On-Line Application for Practicum

Please fill in the box, read carefully, and then click the "Submit" button below.

Application for Practicum Beginning (semester/year)
Name
Date Submitted (dd/mm/year)
Student ID (xxxxxxx)
Home Phone (xxx-xxx-xxxx)
Work Phone (xxx-xxx-xxxx) Ext.
Mailing Address
E-mail Address

ESU Advisor
Program Emphasis

(check one)

Name

Your advisor's signature is required on your application for Practicum. Either print off the PDF application and mail to your advisor for their signature, or have your advisor send the Community Counseling Services Director an e-mail in support of your application to enroll in Practicum. An e-mail from your advisor will serve as their signature. It is your reponsibility to have your application signed by your advisor.


Documentation providing evidence of Professional Liability Insurance coverage must be attached to this application. You will also need to bring an actual hard copy of your professional liability insurance certificate to your personal interview.

**Please paste a copy of your certificate of insurance in this text box**

I plan to complete my practicum experience at (check one):

Community Counseling Services (ESU Campus)
Metro Learning Center (Kansas City)


REQUIRED PREREQUISITES to enroll in Supervised Practicum
 
Term Completed
Grade

For Mental Health Couseling Students

MH700 Introduction to Mental Health Counseling
RE734 or SC810 Pre-Practicum: Counseling Skills Development
MH735 or SC825 Theory and Practice of Counseling
MH790 or MH891 Professional, Ethical, & Legal Issues in Counseling
MH830 or SC850 Group Processes in Mental Health Counseling

For Rehabilitation Counseling Students

RE734 or SC810 Pre-Practicum: Counseling Skills Development
MH735 or SC825 Theory and Practice of Counseling
MH790 or MH891 Professional, Ethical, & Legal Issues in Counseling

For School Counseling Students

SC700 Introduction to Secondary School Counseling
SC705 Intro to Elementary/Middle School Counseling
SC710 Multicultural Counseling
SC715 Parenting and Parent Consultation
SC805 Professional and Ethical Issues in Counseling
SC810 Pre-Practicum: Counseling Skills Development
SC825 Counseling Theories
SC820 Career Counseling & Development
SC850 Group Counseling Theory


**Please paste your unofficial transcript in this text box**


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