Practicum Application

Practicum Application
STUDENT APPLICATION FOR
PRACTICUM IN SCHOOL PSYCHOLOGY
Name:
Phone #:
___________________
____________
_
Student ID #: ____________________ _
University Email: _________________
Practicum Semester: ________ Practicum Year: ___
Year in Program: _______
□ 7P:237 (First year)
□ 7P:337 (Advanced)
Practicum Level:
Goal Areas for Practicum (List areas you would like to develop through practicum
experience in order of preference: e.g., first priority is 1)
Assessment
Intervention
Consultation
__ Intelligence
__ Academic
__ Teacher
___Achievement
__ Individual
__ Parent
__ Social/Emotional
__ Group Skills
___ Community
__ Functional/Behavioral
__ Behavioral
___ Integrated Services
__ Curriculum-Based
__ Prevention
___ Task Force
________________________________________________________________________
Special Considerations (Please note any additional interest areas or constraints)
Age/Grade Level: _________________________________________
_____
_
Population: ____________________________________________________________
Distance/Transportation: _________________________________________________
School, Community or Clinic Setting: ___________________________ ___________
Days Available:
Monday □Tuesday □Wednesday □Thursday □Friday
Full Day
Full Day
Full Day
Full Day
Full Day
(Availability must be for one full day or two half days)
STUDENT APPLICATION FOR
PRACTICUM IN SCHOOL PSYCHOLOGY
Specific Goals (Please list further criteria you would like considered in your placement.)
** Indicate goals anticipated that may assist in identifying potential sites and experiences
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. _______________________________________________________________
Prior Experience (Please indicate skills you will bring to this site in terms of previous
practica, clinical work, employment, professional experience, volunteer experience, and
or course work.)
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. _______________________________________________________________
Special Skills (Please indicate personal traits such as: bilingual skills, organizational
skills and or any special training such as: ASL, Behavior Analyst Certification (BCBA or
BCaBA, etc.)
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. _______________________________________________________________
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