Family Services of Plano

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Intern / Practicum Online Application

Thank you for your interest in Family Services of Plano! Please take a quick moment to complete the application form below.

First Name	*	Last Name	*
Address	*
City	*	State	*
Zip	*

Day Phone	*
Mobile Phone
Email

Students Only
University Supervisor	*
Expected Graduation	*
Current Accumulated Supervised Hours
*Students must present agency with a copy of their professional liability insurance upon acceptance in our program.

Interns
Graduation Date	*
University	*
Temporary License Date		*
Current Accumulated Hours Towards Licensure
*Interns must present agency with a copy of their temporary license and professional liability insurance upon acceptance in our program.

How did you hear about Family Services of Plano? *


What would you like to get out of your experience at Family Services of Plano? *


Name Specific client populations that are of interest to you or that you wish to expand your expertise? (ie. specific disorders, child/adolescent, marital counseling, etc.)


Have you ever been in counseling before? Brief statement of the purpose and outcome?


What do you believe to be your strengths and your possible weaknesses to address in your training?