ࡱ> HJGC c bjbj 4<hhc,"XXXXX333=??????$jc33333cXXx3XX=3=X@P;nIj)003333333ccY3333333333333333X J: Application for Counseling Practicum & Internship ɫֱ, Counseling Education Program: Return to Program Coordinator Practicum/Internship Semester: Fall 20_____ Spring 20_____ Summer 20_____ (circle one) Student Name _________________________________ ID Number____________ Address _____________________________________________________________ City___________________________________ State____________ Zip________ Contact: Home_______________ Cell________________ Work_______________ ext. ____ NSU E-mail: ______________________________ Counseling Concentration Area: Mental Health ( School ( **Sites must be counseling oriented and supervision must be done by someone on site who has a license (LPC, LCSW, CSAC, etc.) or doctorate in a mental health-related field. Course(s) taken prior to Practicum: Course # Course Title Semester Taken  Masters candidates who are taking the clinical practicum must get preapproval from their assigned faculty advisor. Student Signature: _______________________________________ Date: ____________ Faculty Advisor Signature: ________________________________ Date _____________ ( Approved ( Not Approved Clinical Coordinator Signature: _______________________________ Date _____________ ( Approved ( Not Approved 2LVhku- . ` s t u ȸvivZNZvv?viv?vihbhbCJOJQJaJhbCJOJQJaJhbhbCJOJQJaJhb5CJOJQJaJh hb5CJOJQJaJhbhbCJOJQJaJ*hT2hb5CJKH OJPJQJ\aJhbCJOJQJ\aJh hbCJOJQJ\aJhbCJOJQJaJhu8CJOJQJaJh hbCJOJQJaJhQ0hb5CJ OJQJaJ 2- . t u   < = z { ( ) N | } d$Ifgdm$ dgdbm$ dgdb$da$gdbm$      < = V ] l m p w x y z { } ( ) L N X Y l m { | } ~ ߰Ұߡvvvvh hbCJOJQJ\aJh hbCJOJQJaJhbCJOJQJaJhbhbCJOJQJaJ% j*h hb5CJ(OJQJaJ(hbhbCJOJQJaJhb5CJOJQJaJh hb5CJOJQJaJhbhb5CJOJQJaJ.} ~  ^kd$$IflF$f  t06    44 laytd$Ifgdm$~   "h hb5CJOJQJ\aJhb5CJOJQJ\aJhbhbCJOJQJ\aJh hbCJOJQJaJh hbCJOJQJ\aJE n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt n^^^d$Ifgdm$kdH$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd4$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd|$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd $$IflF$f  t06    44 layt n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt n^^^d$Ifgdm$kdh$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd $$IflF$f  t06    44 layt n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt n^^^d$Ifgdm$kdT$$IflF$f  t06    44 layt n^^^d$Ifgdm$kd$$IflF$f  t06    44 layt 1 2 ncc^JJc^d&dPgdbm$gdb dgdbm$kd $$IflF$f  t06    44 layt ' . / 1 2 E  ( 6 > ? rcPCPChb5CJ(OJQJaJ(% j*h hb5CJ(OJQJaJ(hbhbCJOJQJaJ#hZhb5CJOJQJ^JaJhbhbCJOJQJaJhT2hb5CJOJQJaJhb5CJOJQJaJh hb5CJOJQJaJhbhbOJQJ^JaJh hbCJOJQJ\aJhb5CJOJQJ\aJ"h hb5CJOJQJ\aJ D E c dgdbm$? C D E F H Q S T V b c hbh5CJOJQJaJhb5CJ(OJQJaJ(% j*h hb5CJ(OJQJaJ(hbhbCJOJQJaJhb5CJOJQJaJh hb5CJOJQJaJ 21h:pb/ =!`"`#`$`% $$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / yt$$If!vh#vf#v#v :V l t065f55 / ytx666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH J`J bNormal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List V@V b Balloon Text dCJOJPJQJ^JaJR/R bBalloon Text CharCJOJPJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y < ~  ? c  } c  8@0(  B S  ?LVe2 V_e3333333LV`s}}bbeLV`s}}be!u8GIbx_ce@VVVc @Unknown G.[x Times New Roman5Symbol3. .[x Arial7$BCambria?Wingdings 27..{$ Calibri5. .[`)TahomaC.,.{$ Calibri LightA$BCambria Math"1hx'q  !``0aaKq@P  $Pb2!xxu Kerns, Keesha M.Kerns, Keesha M. Oh+'0  < H T`hpxKerns, Keesha M.NormalKerns, Keesha M.3Microsoft Office Word@@?\@yn ՜.+,0 hp  TLAB a  Title  !"#$%&()*+,-./012345689:;<=>@ABCDEFIRoot Entry F0=nKData 1Table'WordDocument4<SummaryInformation(7DocumentSummaryInformation8?CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q