Central connecticut state university

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CENTRAL CONNECTICUT STATE UNIVERSITYDepartment of Counselor Education & Family TherapyStudent Development in Higher EducationApplication for Practicum – CNSL 503NAME: __________________________________________ ID. # ___________________________DAY TIME PHONE: _______________________________DATE: _________________________E-MAIL ADDRESS: ___________________________________________________________________Eligibility Requirements (due at time of first class):Practicum agreement with a college/university, with appropriate supervision (SDHE-2)Proof of professional liability insuranceTaskstream accountNOTE: The forms are available in the spinner outside of the office (Carroll Hall) or online via the Program Web page. Deadlines:March 15Summer PracticumOctober 15Spring PracticumI wish to apply for admission into CNSL 503, Supervised Counseling Practicum, for the following semester:Semester: FORMCHECKBOX Spring FORMCHECKBOX Summer Year ____________514353365500Advisor ApprovalI have reviewed the student’s file, including the C3 survey and transcripts, and certify that the student is ready to enter CNSL 503 Supervised Counseling Practicum. _______________________________________________________Signature of AdvisorDateSuggestions for potential Practicum sites as discussed with student:

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