Clinical Counseling Psychology Application
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CLINICAL COUNSELING PSYCHOLOGY APPLICATION Thank you for your interest in applying to the Clinical Counseling Psychology Masters Program at Brenau University. Please complete all information requested and mail this form to the Brenau University Office of Graduate Admissions, 500 Washington Street SE, Gainesville, GA 30501 or fax to 770.718.5338. PERSONAL INFORMATION ___________________________________________________________ Name: ____________________________________________________________________________________ Address: ____________________________________________________________________________________ City/State/Zip: __________________________________________________ Phone: __________________ Email: __________________________________________________ Cell Phone: __________________ Currently I am taking _______ credit hours. Currently I am working ________ hours/week. I am applying for Fall semester _______. I am applying for Spring semester _______. I am applying as a Full-time Student ______. I am applying as a Part-time Student______. EXPERIENCE ____________________________________________________________________ List employment in areas related to psychology. If you have not been employed in this area, note "not applicable". Please place volunteer experiences in the next section. Employer (agency/setting) Location Type of Clients Description of Work Hours/week Dates Supervisor ___________________ _______ _____________ _______________ __________ _______ _________ ___________________ _______ _____________ _______________ __________ _______ _________ ___________________ _______ _____________ _______________ __________ _______ _________ ___________________ _______ _____________ _______________ __________ _______ _________ List the volunteer experiences you have had in psychology related areas or programs. Employer (agency/setting) Location Type of Clients Description of Work Hours/week Dates Supervisor ___________________ _______ _____________ _______________ __________ _______ _________ ___________________ _______ _____________ _______________ __________ _______ _________ ___________________ _______ _____________ _______________ __________ _______ _________ ___________________ _______ _____________ _______________ __________ _______ _________ List any short term observations or “shadowing” you have done in psychology related areas. Setting Type of clients Supervisor Total Hours/ Dates ___________________ _______________________ ___________________________ ___________________ ___________________ _______________________ ___________________________ ___________________ ___________________ _______________________ ___________________________ ___________________ Revised: 12.10.9 dpg List any research experience you have had in psychology related areas or programs. Research Experience Topic Names of Other Researchers Total Hours/ Dates ___________________ _______________________ ___________________________ ___________________ ___________________ _______________________ ___________________________ ___________________ ___________________ _______________________ ___________________________ ___________________ PRE-REQUISITE COURSEWORK _______________________________________________________________ There are two pre-requisite courses that are required to be taken before taking certain graduate courses. These courses are: Abnormal Psychology and Research Methods (or Statistics). Indicate your status on the prerequisite courses. Course Number & Title Semester Completed Will be Completed Institution Grade Introductory Statistics ___________________________ _________ _________ ___________ _____ Research Methods ___________________________ _________ _________ ___________ _____ Abnormal Psychology ___________________________ _________ _________ ___________ _____ Undergraduate major ____________ Major GPA________ Undergraduate minor _____________ Date degree received/expected __________ Psychology coursework GPA (if non-psych major)_________ Cumulative GPA _________ Do you have previous masters level coursework or a masters degree? _________ RECOMMENDATIONS _______________________________________________________________ Provide two academic or professional recommendations. GRADUATE RECORD EXAMINATION (GRE) ________________________________________________ Have you taken the GRE within the past 5 years? _______ Score: Verbal ______ ______________ Quantitative ______ WRITING SAMPLE ________________________________________________________________ Write an essay (approximately 2 to 3 pages) that addresses your future professional goals, your goodness of fit with the program at Brenau, and your reasons for aspiring to a degree in Clinical Counseling Psychology. APPLICANT AGREEMENT ____________________________________________________________ My signature below indicates that all information in my application is complete, factually correct and honestly presented. I understand that failure to provide accurate and true information may invalidate my admission to Brenau University. I have read and understand the admissions policy of Brenau (catalog can be found at www.benau.edu/reg/catalog). If my application is accepted and I become a student, I agree to abide by all policies and regulations of Brenau University, including the student honor code. I further certify that the attached written essay is my own work. Signature of Applicant:_________________________________________ ______________Date: ______________________ Revised: 12.10.9 dpg
