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Application for Internship
Clinical Mental Health Counseling
Directions: Complete the entire application. Fill out each box. Attach your resume and a copy of your most recent academic transcript. Applications with missing information will not be considered for any internship. Return this completed form to the Practicum and Internship Committee Chair. The deadline to submit this form is on or before March 17th by 5:00 pm. Thank you for your time.
Name (Last , F i r s t , M i d d l e ) : F O R M T E X T C a m p u s :
F O R M C H E C K B O X R a d f o r d U n i v e r s i t y
F O R M C H E C K B O X A b i n g d o n R U S t u d e n t I d #
F O R M T E X T S t r e e t A d d r e s s : F O R M T E X T
C i t y , S t a t e & Z i p : F O R M T E X T E m a i l :
F O R M T E X T H o m e P h o n e :
F O R M T E X T W o r k P h o n e :
F O R M T E X T O t h e r P h o n e : F O R M T E X T
I n d i c a t e s e m e s t e r a n d y e a r w h e n y o u e n t e r e d t h e p r o g r a m :
F O R M C H E C K B O X S u m m e r o r F a l l F O R M T E X T
Y e a r
P r o s p e c t i v e g r a d u a t i o n d a t e :
F O R M C H E C K B O X D e c e m b e r F O R M T E X T
Y e a r
F O R M C H E C K B O X M a y F O R M T E X T
Y e a r P r e f e r e n c e f o r t h e i n t e r n s h i p c o u r s e ? P l e a se note: The internship class will meet once per week throughout the entire semester.
FORMCHECKBOX AM class
FORMCHECKBOX PM Class
Indicate the semester and year in which you plan to be enrolled in internship:1st Internship:
Semester: FORMTEXT
Y e a r : F O R M T E X T 2 n d I n t e r n s h i p :
S e m e s t e r : F O R M T E X T
Y e a r : F O R M T E X T 3 r d I n t e r n s h i p ( o p t i o n a l f o r a d d i t i o n a l l i c e n s u r e h o u r s ) :
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