Extern/Pract. Application

NAME:

LOCAL ADDRESS:

HOME ADDRESS:

PHONE NUMBERS (home and office):

_______________________________________________________________________________________

1. Graduate school in which you are enrolled

Department:

Degree Program:

If practicum/externship is to fulfill a course requirement, indicate the course, name, number, and name of the instructor:

2. What type(s) of experience will you be seeking in your HUCS Practicum/Externship:

Psychological Testing/Assessment
Diagnostic/Intake Interviewing
Vocational/Career Counseling
Individual Counseling/Psychotherapy
Group Counseling/Psychotherapy
Couples Counseling
Family Therapy
Other (specify)

3. Education: (Undergraduate, Graduate, other)

Institution	From	To	Degree	Date

4. If you have had clinical supervision before, please give: names, addresses, and telephone numbers of previous supervisors

NAME

ADDRESS

TELEPHONE

5. If you have had professional work experience work experience, list them on a separate sheet, or include your curriculum vitae

6. Include transcripts showing your graduate course work.

7. Three letters of recommendation

______________________________________________________________________________________________________________

I HEREBY AUTHORIZE THE HOWARD UNIVERSITY COUNSELING SERVICE TO
CONTACT PRESENT AND FORMER INSTRUCTORS AND SUPERVISORS IN
CONNECTION WITH THIS APPLICATION.

SIGNED DATE

______________________________________________________________________________________________________________

Submit application package to:

Director Dr. Marcus Hummings

mhummings@howard.edu

Howard University Counseling Service
6^th & Bryant Streets, N.W.
Washington, D.C. 20059

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