UNC Charlotte Counseling Center

Practicum Application

Date ______________________

Name ___________________________________________________________

Department ______________________________________________________

Phone number(s) __________________________________________________________

1. List clinical or counseling coursework completed or in progress:

2. List any previous clinical or counseling experiences and supervisors. Please list phone numbers of supervisors.

3. Rate your skills in the following areas on a scale of 1 (poor) to 5 (excellent). Provide examples of each area of experience. In areas where you have no experience, indicate N/A.

a. Intake Interview:

b. Diagnosis:

c. Individual Counseling:

d. Group Counseling:

e. Case Conceptualization integrating theory

f. Multicultural Competencies

4. What are your professional goals?

5. Availability during work hours (8-5). Must Document 20 hours of availability. Also note if you are available for Professional Development seminar on Thursday mornings from 8:30am – 10:00am.

6. Have you have completed the following courses:

Y N Counseling/Clinical theory and techniques

Y N Ethics

Y N Personality or Abnormal psychology

Y N Multicultural counseling

Y N Research design and methods

Y N Group therapy

Return completed application, a short resume, and a letter of reference to:
Jessica A. Walker, Ph.D., Practicum Coordinator,

Counseling Center, 158 Atkins Building