Practicum Documents

COUN 5689 Clinical Practicum Documents

Complete the required entries and upload documents in the areas specified below.

Student Name: *

Texas State email address: *

Phone number: *

Practicum Professor Last Name: *

Degree Track: *

Semseter for which you are submitting Clinical Practicum documents: *

Year of Practicum Semester *

Required Clinical Practicum Documents

Provide scanned copies or pictures of the required documents here.

Your University Professor will let you know if hard copies of documents will be required, so please keep the hard copies.

1.) Attach a copy of current Liability Insurance in effect for the duration of the semester

2.) Attach a copy of the signed Group Co-Facilitator Agreement

3.) Attach a copy of Group Co-facilitator Evaluation at end of semester

Complete the following information:

Name of agency:

Agency address:

Agency phone:

Site supervisor’s name & credentials:

Site supervisor’s e-mail address:

Group Co-Facilitator must licensed and hold one of the following credentials. [Board approved supervisor status is not required.]

Additional information:

If you happen to see this, do not fill this field.