Internship Application

Name:		Date:
Local Address:		Summer Address:
City:	State:	City:	State:
Local Phone Number:		Summer Phone Number:
Formal Education: Please list courses and instructors you have taken which you regard as having contributed to your preparation for this counseling intern/trainee position, how they have helped prepare you and the dates completed.
Experience: Please list those experiences which you have had that you regard as relevant in preparing you for an internship in counseling and the dates when they occurred.
Additional Comments: We would appreciate the inclusion of any additional information you would like to share regarding your personal philosophy, counseling orientation, professional and personal aspirations, interests and experiences.
References: Minimum of three. Please give the name(s) of your practicum instructor(s)/SW Practicum instructor(s) and supervisor(s), their phone number(s) and the dates of completion. Also provide one or two additional references you would like to include to be contacted for recommendation, their relationship to you and phone number.
Prospective Graduation Date: