ALABAMA AGRICULTURAL AND MECHANICAL UNIVERSITY
DEPARTMENT OF PSYCHOLOGY AND COUNSELING
Application for Internship
PERSONAL DATA
Name:
SI#:
Address:
Street
City
Home Phone:
State
Zip
Work Phone:
What is your major?
Clinical
Counseling
ACADEMIC DATA
Major:
Electives:
1.
1.
2.
2.
3.
3.
4.
Elective Courses Currently in Progress:
5.
1.
6.
2.
7.
3.
8.
Major Courses Currently in Progress:
1.
2.
3.
Expected Date of Graduation:
Will you have completed all coursework by the end of this semester or by the time of internship placement?
YES or NO
How many courses are lacking?
Note:
Please submit a copy of your transcript with application.
WORK EXPERIENCE:
Paid:
Where do you work now?
Where did you work prior to your current job?
Where did you do your Practicum?
Volunteer:
Places where you have done volunteer work:
Preference for Internship Experience (not place of internship): (Indicate areas of interest by #1, 2, 3, etc.)
Clinical Psychology Majors
Counseling Majors
Elderly/aged/gerontology
School (Mental Health Center)
Mental Retarded
Univ/College Counseling
Alcoholic & Substance Abuse
(Hospital Setting)
Career/Vocation Counseling
Mental Health/Illness
Personal Growth & Adjust
Family Counseling
Vocational Rehabilitation
Corrections
Employment Agency
Psychiatry
Vocational Rehabilitation
(Neuropsych & Rehab Medicine)
Comments:
DO NOT WRITE IN THE SPACE BELOW.
Internship Placement:
Semester of Placement:
Completion Date:
Grade:
Please submit the following along with your application
for internship:
1. A Current Professional Liability Insurance for Students
· 2. A National Background Check
· 3. A Drug Test which shows Negative Results (10 Panel
Rapid Urine)
· 4. A Tuberculosis Screening Test
· 5. Two Letters of Reference
6. Schedule of internship hours to be signed and returned
NO APPLICATIONS WILL BE
ACCEPTED AFTER
APRIL 28, 2015