Externship / Practicum Application

Application Deadline: March 4th 2013

Please Print or Type

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.

 

SignedDated

 

Submit application package to the Program Coordinator:

Marcus Hummings, Psy.D. mhummings@howard.edu

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

Last updated Feb, 2013