Please Print or Type
PHONE NUMBERS (home and office):
1. Graduate school in which you are enrolled:
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:
3. Education: (Undergraduate, Graduate, other):
4. If you have had clinical supervision before, please give: names, addresses, and telephone numbers of previous supervisors:
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.
Submit application package to the Program Coordinator:
Marcus Hummings, Psy.D. email@example.com
Howard University Counseling Service 6th & Bryant Streets, N.W. Washington, D.C. 20059