Instructions
1. Applicants must complete all course prerequisites required by their program and be in good
academic standing to be considered for practicum/internship.
2. Permission of the Practicum/Internship Director is required prior to seeking a field placement.
3. If Practicum/Internship Director determines you are eligible for field placement, you will be
enrolled in a practicum or internship course and assigned to a faculty supervisor.
4.
Approval does not guarantee placement. Refer to the university catalog or contact the
Practicum/Internship Director for more information.
5. A new application is required for each semester of field placement.
6. A minimum of two weeks prior to the first class day in the semester you intend to begin your
field work assignment, you must submit to the Administrative Assistant in the Psychology and
Counseling Department (Warrior Hall 318) the following documentation:
a. A copy of the Practicum/Internship Agreement for your training program that includes
your signature and the signature of your site supervisor. Your faculty supervisor will sign
the Agreement and provide you with a signed copy after the first day of class.
b. Proof of liability insurance (see p. 10 of this document for more information).
7. Students who will be earning Practicum I hours in the on-campus clinic (i.e., CMCH, MFT, and
48-hour LPC/LMFT students) will also need to complete a separate set of application materials
specifically for the Clinic and attend the Clinic’s orientation. These materials are typically due to
the Clinic 1 week prior to the deadlines for applying for Practicum.
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Psychology and Counseling Department Practicum/Internship Application
Texas A&M University – Central Texas
Please complete the attached practicum/internship application materials and return them to the
Psychology and Counseling Department office by the following deadlines. Space in practicum/internship
courses is limited.
Fall – June 1st
Spring – November 15th (deadline moving to 9/1 for Spring 2017)
Summer February 1st
____ Application (p. 2)
____ Verification of eligibility (p. 5-8)
____ Statement on Confidentiality (p. 3)
____ Self-inventory for practicum/internship selection (p. 9)
____ Waiver/Liability Release Form (p. 4)
Student: ________________________________
myCT Email: ______________________________
Student ID Number: ______________________
Other Email (optional): ______________________
Mailing Address: _________________________
City/State: ____________________ Zip: ________
Telephone (H): __________________________
Telephone (C): _____________________________
Program:
 Clinical Mental Health Counseling (60-hour)
 Marriage & Family Therapy (60-hour)
 48-Hour LPC
Semester Requested for Field Placement:
Year: _______
 Fall
 Spring
 Summer
School Counseling
Specialist in School Psychology
48-Hour MFT
MFTK 530
MFTK 554
MFTK 559
MFTK 560
MFTK 561
Course Requested:
PSYK 505
PSYK 584
PSYK 587
PSYK 595
PSYK 596
MHCK 505
MHCK 595
CNSK 595
CNSK 596
Have you identified a site where you intend to complete your hours? YES/NO (circle one)
If yes, complete the fields below:
Name of Site: ____________________________
Supervisor: ________________________________
Physical Address of Site: ______________________________________________________________
Supervisor Email: ________________________
Supervisor Phone: __________________________
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PSYCHOLOGY AND COUNSELING PRACTICUM
Texas A&M University – Central Texas
Statement of Confidentiality
I, the undersigned, do agree to hold in strictest confidence personal information gained in a
practicum/internship. This agreement is in accordance with established Codes of Ethics from professional
associations as well as the licensure laws of the state of Texas. I understand the necessity for such an
agreement and will abide by the implicit and explicit demands of this statement. I further understand that
breaches of confidentiality will result in disciplinary action including possible dismissal from the Texas
A&M University – Central Texas Psychology and Counseling Department.
_____________________________________________
Student
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_______________________
Date
AFFIRMATION, WAIVER, AND LIABILITY RELEASE
TEXAS A&M UNIVERSITY – CENTRAL TEXAS
PSYCHOLOGY AND COUNSELING PRACTICUM
In consideration of being allowed to participate in a practicum/internship course and the field placement
requirement of said course, the undersigned student agrees:
1. To waive all claims for liability against Texas A&M University – Central Texas, the Board of
Regents, the Texas A&M University System, their respective officers, agents, servants, and
employees, arising or in any way predicated upon acts or omissions, in connection with the above
described class and program. The undersigned agrees to hold harmless Texas A&M University –
Central Texas, the Board of Regents, the Texas A&M University System, their respective officers,
agents, servants, and employees from any and all liability arising out of, or in any manner
predicated upon, loss or damage to property, injury or death to the undersigned, which injury may
occur in connection with the operation of the above described class and program, regardless
whether or not such injuries arise, in whole or in part, from the negligence of TAMUCT or its
employees.
2. That his/her participation in said class will make use of personal student experiences in group and
individual supervision in classroom settings, and I hereby give my informed consent to the usage
of these experiences and further agree and consent that professional observations and/or findings
as well as student comments may be communicated to and discussed with the group in a
classroom situation. The undersigned agrees to hold harmless Texas A&M University – Central
Texas, the Board of Regents, the Texas A&M University System, their respective officers, agents,
servants, and employees from any and all liability arising out of or in any way predicated upon
acts or omissions, in connection with the activity described in this paragraph.
3. To hold harmless Texas A&M University – Central Texas, the Board of Regents, the Texas A&M
University System, their respective officers, agents, servants, and employees from any and all
liability arising from participation in the field practicum/internship or which might be due to
injuries as a result of the co-trainer’s negligence. Co-trainer represents any agency, institution, or
facility outside Texas A&M University – Central Texas that accepts responsibility of supervising a
student intern.
4. That he/she assumes all risk involved in participation in this field practicum/internship program.
This assumption is made freely and voluntarily and with full and complete understanding of the
consequences of such risk assumption.
5. That his/her fitness for providing counseling services will be continually monitored by faculty and
on-site supervisors, and I hereby give my informed consent for my faculty supervisor, on-site
supervisor, and practicum/internship director to share information about my performance to
facilitate this evaluation.
____________________________
Date
__________________________________________
Student Signature
____________________________
Date
__________________________________________
University Representative Signature
4
VERIFICATION OF ELIGITIBLITY
*Complete only the section for the degree program you are completing*
M.S. in Clinical Mental Health Counseling
I certify that I have completed the following pre-requisite courses for MHCK 505 or MHCK 595.
Required Course
Semester/Year
School
MHCK 550: Foundations of Cnsl and Psych
MHCK 591: Ethical Foundations of Cnsl
MHCK 553: Personality & Cnsl Theories & App
MHCK 557: Methods & Practices in Cnsl & Psych
MHCK 554: Group Procedures for Counselors
MHCK 558: Cnsl Perspectives on Psychopathology
MCHK 505: Practicum I (If applying for MHCK 595)
Grade
I also certify that my cumulative graduate school grade point average (GPA) at Texas A&M-Central Texas is
3.0 or greater and that I earned a grade of B or higher in all prerequisite courses.
Student Signature _______________________________
Date __________________
M.S. in Marriage and Family Therapy
I certify that I have completed the following pre-requisite courses for MFTH 530, 554, 559, 560, or 561
Required Course
Semester/Year
School
Grade
MFTK 501: Introduction to MFT Theory
MFTK 507: Ethics in MFT
MFTK 520: Pre-Practicum
MFTK 530: Clinical Practicum 1 (If applying for Prac 2)
MFTK 554: Clinical Practicum 2 (If applying for Prac 3)
MFTK 559: Clinical Practicum 3 (If applying for Prac 4)
MFTK 560: Clinical Practicum 4 (If applying for Prac 5)
MFTK 561: Clinical Practicum 5
I also certify that my cumulative graduate school grade point average (GPA) at Texas A&M-Central Texas is
3.0 or greater and that I earned a grade of B or higher in all prerequisite courses.
Student Signature _______________________________
Date __________________
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VERIFICATION OF ELIGITIBLITY
*Complete only the section for the degree program you are completing*
M.E. in Counseling Psychology: School Counseling Option
I certify that I have completed the following pre-requisite courses for CNSL 595/596.
Required Course
Semester/Year
School
CPSY 550: Foundations of Cnsl and Psych
CPSY 551: Career Cnsl & Guidance
CPSY 553: Personality & Cnsl Theories & App
CPSY 554: Group Procedures for Counselors
CPSY 557: Methods & Practices in Cnsl & Psych
PSY 581: Assessment & Evaluation Fundamentals
CNSL 595: Practicum I (If applying for CNSL 596)
Grade
I also certify that my cumulative graduate school grade point average (GPA) at Texas A&M-Central Texas is
3.0 or greater and that I earned a grade of B or higher in all prerequisite courses.
Student Signature _______________________________
Date __________________
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VERIFICATION OF ELIGITIBLITY
*Complete only the section for the degree program you are completing*
M.S. in Educational Psychology: School Psychologist Option
I certify that I have completed the following pre-requisite courses for PSY 505, 595, or 596
Required Course
Semester/Year
School
PSY 560: Foundations of School Psych
PSY 582: Behavior Management & Therapy
CPSY 553: Personality & Cnsl Theories & App
CPSY 557: Methods & Practices in Cnsl & Psych
PSY 581: Assessment & Evaluation Fundamentals
CPSY 558: Cnsl Perspectives on Psychopathology
-OREDSP 505: Introduction to Exceptional Learners
PSY 505: Practicum I (If applying for PSY 595)
PSY 500 Behavioral Statistics (If applying for PSY 595)
PSY 501 Research Methods (If applying for PSY 595)
PSY 502 Social Psych Processes (If applying for PSY 595)
PSY 503 Theories of Learning (If applying for PSY 595)
PSY 504 Human Development (If applying for PSY 595)
PSY 560 Foundations of School Psych (If applying for PSY 595)
PSY 511 Cult, Min & Gender Issues (If applying for PSY 595)
PSY 514 Assmt of Intell & Ach (If applying for PSY 595)
PSY 515 Physiological Psych (If applying for PSY 595)
PSY 580 Personality & Social Assmt (If applying for PSY 595)
PSY 583 Consultation & Supervision (If applying for PSY 595)
EDU 538 Curr Design & Implem (If applying for PSY 595)
EDAD 512 Admin of Elem & Sec Schools & Spec Serv (If
applying for PSY 596)
PSY 595 Internship (If applying for PSY 596)
Grade
I also certify that my cumulative graduate school grade point average (GPA) at Texas A&M-Central
Texas is 3.0 or greater. I also certify that I earned a grade of B or higher in all prerequisite courses for
PSY 505: Practicum I.
Student Signature _______________________________
Date __________________
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VERIFICATION OF ELIGITIBLITY
*Complete only the section for the degree program you are completing*
M.S. in Counseling Psychology: 48-hour LPC option
I certify that I have completed the following pre-requisite courses for PSY 505
Required Course
Semester/Year
CPSY 550: Foundations of Cnsl and Psych
CPSY 553: Personality & Cnsl Theories & App
CPSY 554: Group Procedures for Counselors
CPSY 557: Methods & Practices in Cnsl & Psych
CPSY 558: Cnsl Perspectives on Psychopathology
PSY 581: Assmt & Eval Fundamentals
School
Grade
I also certify that my cumulative graduate school grade point average (GPA) at Texas A&M-Central Texas is
3.0 or greater.
Student Signature _______________________________
Date __________________
M.S. in Counseling Psychology: 48-hour LMFT option
I certify that I have completed the following pre-requisite courses for PSY 505
Required Course
Semester/Year
CPSY 550: Foundations of Cnsl and Psych
CPSY 509: Assmt & Trtmt in Marr & Fam Therapy
CPSY 553: Personality & Cnsl Theories & App
CPSY 556: Introduction to Family Cnsl & Therapy
CPSY 557: Methods & Practices in Cnsl & Psych
CPSY 558: Cnsl Perspectives on Psychopathology
School
Grade
I also certify that my cumulative graduate school grade point average (GPA) at Texas A&M-Central Texas is
3.0 or greater.
Student Signature _______________________________
Date __________________
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SELF-INVENTORY FOR PRACTICUM/INTERNSHIP SELECTION**
Directions: Prior to enrolling in practicum or internship students are asked to complete this self-inventory.
1.
My long term career goal is:
2.
My area of special interest is:
3.
The type of client who I would most like to work with is:
4.
The type of client who I would least like to work with is:
5.
I feel most qualified/skilled to work with:
6.
I feel least qualified/skilled to work with:
7.
An area of competence I would like to enhance or develop is:
8.
My ideal site supervisor would have the following characteristics:
9.
I feel most comfortable in a working environment with the following characteristics:
10.
I have had the following professional or volunteer experience and/or course work related to counseling:
11.
My personal areas of strength and weakness which should be considered in the site selection process
include.
a. Strengths:
b. Areas for improvement:
12.
My ideal counseling internship would be a(n) ____________________________________ agency
performing ________________________________ duties with _______________________________
(type of population).
**Ideally you should complete this form prior to contacting sites, and then use the information herein when
consulting with your program advisor or the practicum/internship director to narrow your search to sites
most appropriate to your needs/expertise.
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INFORMATION ON LIABILITY INSURANCE
You must obtain counselor professional liability insurance before your application for practicum/internship will be
deemed complete. You may obtain liability insurance from an insurance company endorsed by a counseling
association. You cannot begin your practicum/internship without this insurance.
Liability insurance may be obtained from:
 American Counseling Association (ACA)
o 1-800-347-6647 ext. 222
o http://www.counseling.org/membership/aca-and-you/students
 Texas Counseling Association (TCA)
o 1-800-580-8144
o http://www.txca.org/tca/BENEFITS.asp
 AAMFT
o CPH & Associates
711 South Dearborn Street
Suite 205
Chicago, IL 60605
http://www.cphins.com/
Direct: 312-987-9823
Toll-free: 800-875-1911
Fax: 312-987-0902
Office Hours: Monday - Friday: 8:30 am – 5:00 pm CST
 National Association of School Psychologists (NASP)
o http://www.nasponline.org/students/insurance.aspx
Information about other providers and coverage is available from:
 Texas Department of Insurance
o 1-800-252-3439
o http://www.tdi.texas.gov/
**Keep this page for your own information**
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