Internship Site Application : Dept of Counseling, Leadership, Adult Education & School Psychology : Texas State University

Name of Internship Site *

Agency or Site Mission *

Website *

Street Address *

City *

State *

Zip Code *

Phone Number *

Person completing this form *

Your role at the agency *

Your email address *

Site Classification *

Agency

College/University

Group/Private Practice

This site type can be discussed with Clinical Director.

Hospital

School

Clients served at this site: *

Check all that apply

Children

Ages 3-10

Adolescents/Pre-adolescents

Ages 11-17

Adults

Ages 18-64

Seniors

Ages 65+

General counseling services provided at this site: *

Check all that apply

Individual counseling

Play therapy

Couples counseling

Family counseling

Group counseling

If you chose Other, what other services are provided at this site?

How are clinical sessions offered? *

If you chose Other, what other services are provided at this site?

Our Marriage, Couple, and Family Counseling students are eager to get relational hours (e.g., couples, family, parent-child, or sibling sessions and groups). How many relational hours could an intern earn each semester at your site? *

Describe responsibilities of an intern at your site *

Preferred qualities of an intern at this site: *

Semesters you can provide a client caseload and weekly individual supervision to an intern: *

Check all that apply

Spring

Summer

Fall

Preferred length of intern commitment: *

No preference

One semester

Two semesters

Approximate number of internship spots available: *

Number of interns you will hire

List any mandatory training required for this site.

Include training hours (e.g., two-day training, 20-hour training)

Any other internship requirements for this site?

(e.g., participation in camps, volunteer events, etc.)

Stipend amount (if applicable):

Offer 300 clock hours of supervised experience (direct counseling and indirect work) each semester *

Yes

No

Provide a minimum of 120 direct client counseling hours each semester *

(About 10-12 clients or direct hours per week)

Yes

No

Provide weekly one-hour individual supervision and be present at the site when the intern is on site *

Yes

No

Allow video and/or audio recording of intern (with client approval) for site and TXST university supervisors to evaluate intern skills *

This requirement can be discussed with Clinical Director.

Yes

No

Offer opportunity for intern to participate in all aspects of work a counselor performs at this site (e.g., individual counseling and group counseling sessions, intakes, clinical staffings, documentation, site events) *

Yes

No

Anything else you would like to share with us about your site? Any additional questions about the requirements noted in this application?

Internship Site Application

To clarify the experiences our students could be seeking:

Practicum: Students co-facilitate groups with a licensed co-facilitator at their site, for a total of 20 group hours in the semester.

Internship: Students earn 300 hours each semester, of which, 120 hours are direct client counseling hours (a majority of hours individual counseling but can also include group counseling - does not have to be co-facilitated).