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Spring 2022 Internship 5389 Application

Spring 2022    SEMESTER DATES:  1/18/22 - 5/11/22

Your degree track determines how you are to fill out this form. Please read and complete carefully.

Email Addresses:

Please rank order your preferences for the following Internship sections (1-4):


Classes Completed:

Please make the course selections below according to your degree track.  Select YES if you are currently enrolled in the course this semester.

COUN 5301
COUN 5305
COUN 5307
COUN 5316
COUN 5328
COUN 5350
COUN 5355
COUN 5367
COUN 5368
COUN 5391

COUN 5354
COUN 5358
COUN 5359
COUN 5369
COUN 5372
Elective: 3 hr

choose one:

COUN 5366 IM Adults
COUN 5373 IM Play Therapy
COUN 5370 IM Adolescents
COUN 5689 Clinical Practicum
COUN 5389
COUN 5389
COUN 5351
COUN 5338

** If there is any other information that needs to be considered with this application regarding section placement (e.g., enrolling in another course that interferes with a particular Internship section or Internship work schedule), you MUST provide that information with this application.

Do not assume that the Internship Coordinator will be aware of individual concerns. **

Required Documents:

Note:  2nd and 3rd term COUN 5389 Internship students do not need to turn in documents #1-3 below, but YOU DO NEED TO TURN IN THIS COMPLETED APPLICATION.

2.) Attach a copy of all Professional Counseling Performance Evaluations (PCPEs) given to you in all required experiential classes (5354; and one of the following: 5360, 5366, 5370, or 5373).

3.) Attach a 1-2 page statement of your counseling strengths and weaknesses.

As of this date, have you been formally accepted at an Internship site?

If yes, please provide the following information:

Policies for acceptance into COUN 5389:

  • Students in their second or third semester of 5389 have the highest priority.
  • Students who have completed the most coursework will have the next highest priority.
  • All supporting documents must be included with your application so that your needs can best be determined.
  • Order of receipt of application will also be used in assignment to course sections.


  • Start searching for internship sites as early in the previous semester as possible. All site supervisors must be approved prior to the start of the internship. Students cannot start an Internship semester without a secured Internship agreement.


Note: Every internship student is required to submit the Memorandum of Agreement, Proposed Internship Activity Plan, and completed Supervisor Disclosure Statement to the Practicum/Internship Coordinator (Dr. Chiles)  before the start of the Spring 2021 semester. These forms are NOT required to be turned in with this application.