Name ______________________________________ Phone ___________________________

Street Address _________________________________________________________________

City ____________________________________ State _______ Zip Code _________________




Institution _____________________________________________________________________

Course of Study __________________________ Degree _______________________________

Field Placement instructor Name ___________________________________________________

Phone ________________ Fax __________________ Email __________________________


Semester (Circle One):             Fall                      Spring                            Summer


Level of Internship (Circle One):            Practicum                            Internship 1                           Internship 2


Clinical Semester Hours Required:  Total ____________  Per Week _____________


Dates: From _______________________ To ________________________


If Practicum or Internship 1, do you plan to continue at the ETSU Counseling Center for multiple semesters? Yes _______  No _______

If yes, what is your projected graduation date? _____________________________


If this is your 1st or 2nd semester of internship, where was your previous placement(s)?

Location/Site _____________________________Hours completed _____________

Location/Site _____________________________Hours completed _____________


Please respond to the following items (on a separate paper, please):


1.      Please describe any emerging interest or practice with a specific counseling/psychological orientation.


2.      List and briefly describe any relevant clinical experience, including observation, groups, role play, and co-therapy.


3.      Write a statement concerning your personal career goals and how you hope an internship within the ETSU Counseling Center will fit with your goals.


    4.  Briefly share your story and how your own personal growth and experience may help you to meet clients where they are.


Please also provide:

a)       three (3) professional references

b)      a copy of your resume



All application materials may be turned in via email to Sarah Bedingfield, LPC-MHSP, ACS at