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New Site Internship Application

Submit this form to the Department of Counselor Education and they will recieve your application for a New Site Internship.

Site Information

Site Name

Website URL

Street Address

City

State/Province

ZIP/Postal Code

Phone Number

Site Fax Number

Agency Contact Name

Agency Contact’s License Number

Agency Contact Title

Agency Contact's Phone Number

Agency Contact's Email Address

What Type of Taping is Allowed?

One or Two Semester Commitment?

Site Hours of Operation

Site Contact's Resume

Site Contact's License

Site Contact's History of Supervision Documentation

Site Contact's Supervision Training Documentation

Description of Site and Clients

By submitting this form you are agreeing that you have read, understand, and agree to uphold the policies outlined in the Site Contract.