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Practicum Pre-approval Form
M.S. Program in Clinical-Counseling Psychology Preregistration Practicum Approval Form (This form must be completed one month prior to the end of the semester prior to practicum and submitted to the Program Coordinator)
Student’s name:______________________________
VSU Faculty Supervisor (Practicum course instructor):___________________________VSU Advisor:______________________________
Student’s Phone: Home:_____________________ Work:_______________________
Student’s email address:__________________________________________Semester of Practicum: term:________ year:________
Has the practicum site been previously approved? YES NO
Practicum Site name:__________________________________________
Site Address:___________________________________________________________
On-Site Supervisor: _______________________ Phone: (____)_________________
Qualifications of Supervisor (degree, license):__________________________________
Type of Clientele (incl. age range):___________________________________________
Activities Available (e.g., type of testing, group/ind. couns.): ______________________
________________________________________________________________________
Type of liability insurance (attach photocopy):_______________________
Term Prepracticum was completed with grade of B or better: term:________ year:________
Term Comprehensive Exams were successfully completed: term:________ year:________
__________________________________________________________________________________
| Signature of Student | Signature of Advisor |