Name *

First Name

Last Name

Phone *

(###)

###

####

I am interested in a practicum for the following semesters (check all that apply):

Fall/Spring

Summer/Fall/Spring (full year) *Required for LMFT + LPC students.

I am interested in the following track:

Therapy

Advanced Neuropsychology Assessment

Have you had any prior experience delivering psychotherapy services?

Yes

No

Are you currently enrolled in or have you taken a Family Therapy course?

Yes

No

Are you currently enrolled in or have you taken a Group Therapy course?

Yes

No

Purchased student liability insurance

Yes

No

Plan to purchase liability insurance

Yes

No