Practicum and Internship
Application
Please fill out the following
information completely and accurately. If more space is needed, please affix an
additional sheet of paper. Please also include a copy of your current resume
with this application. Please see below for submission methods.
Name: _________________________________________________________
School phone number: _____________________________________________
School address: __________________________________________________
Permanent address: __________
____________________________________
Permanent phone number:
_________________________________________
Email address: ___________________________________________________
Major / concentration:
_____________________________________________
Is this a Practicum or
Internship? ___________________________________
Hours / Credit hours
required: ___________
Semester/Year you are
applying for:________________________________
Days preferred:
________________________________________________
Professional aspirations:
_________________________________________
What Counseling areas/topics
interest you most (be specific):
Why do you want to do your
Practical / Internship experience at SU’s Counseling
Services (as opposed to another site)?
____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What core classes have you taken in school that would prove
advantageous for SU?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What type of supervisory
style best suits your learning needs?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Please list two references
and their contact information: _________________________________________________________________
_________________________________________________________________
Please list your academic
coordinator / advisor and their contact information:
_________________________________________________________________
__________________________________________________________________________________________________________________________________
For more information or if
you have any questions please contact Nancy Schulte, Counseling Services,
540-665-4530 or nschulte@su.edu.
Applications may be sent via
mail, email or faxed to Nancy Schulte at: