Counseling Students
Forms for Practicum and Internship

PLEASE NOTE:  All of the forms are provided in PDF format. Viewing of the handouts requires Adobe Acrobat Reader. If Adobe Acrobat Reader is not installed on your computer, please visit the Adobe Acrobat Reader's Download Page.

After printing a form, you may wish to fax the completed form to the department. 
The main campus FAX number is:  1-662-325-3263.  The Meridian campus FAX number is 1-601-484-0279.

Evaluation Forms

Additional School Counseling Forms

These forms are used during the practicum/internship experience.  It is not necessary to copy or submit these forms as part of the practicum or internship application.

Please submit a student data form to give us current information about mailing address, phone numbers, site supervisor data, e-mail address, etc.

The following affiliation forms may be used with either practicum or internship sites.

• Agreement between MSU and school:  This is a document which defines the relationship between the school district and the department. The agreement includes a reference to a specific job description for the graduate student, to include concrete goals and expectations (see the MCAI form). 

• MCAI Specific duties:  This is a document which incorporates the 11 MCAI competencies with specific job expectations of the practicum/internship.

The following forms may be used by practicum students when obtaining permission to record counseling sessions and when obtaining permission for a pupil to participate in a case study.

• Case Study Outline:  This outline may be used to complete the case study requirement in the school counseling practicum.

• Release form:  This form may be used to inform clients about recording counseling and to receive permission to do so.

• Release form for case study:  This form may be used to inform clients about the nature of a case study and to receive permission to use the client as the subject of a case study.

• SOAP notes:  A useful format to follow when making progress notes about student clients.

• Tape Critique Form:  This form may be used when writing an evaluation of a recorded counseling session.  You also may access a "MS-Word version" so you can complete the form on your computer.

Internship (Doctoral)

• Doctoral Internship Application
• APPROVAL FORM FOR INTERNSHIP STUDENTS TO RECEIVE BOTH INDIVIDUAL AND GROUP SUPERVISION ON-SITE
• Doctoral Internship Weekly Log may be used by doctoral students and their supervisors. This form is most applicable to doctoral students who are providing counseling, supervision, and teaching services. As noted previously, interns and supervisors are to develop goals and objectives for the intern’s placement. Students and supervisors are encouraged to create forms that are tailored to these goals and objectives.
• Activities Summary Sheet Example.  At the conclusion of the internship, the intern and supervisor are to review the progress made in meeting goals and objectives. A summary of how each goal/objective was or was not met should be submitted to the internship instructor. If certain goals or objectives were not met, the intern needs to note briefly the reasons why this occurred. In addition, an "Activities Summary Sheet" must be signed by the intern and supervisor and submitted to the internship instructor  This summary should delineate the major activities in which the intern engaged, the total number of hours spent in each activity, and the percentage of time spent in each activity.
• On-Site Supervisor's Doctoral Internship Evaluation
• Student Evaluation Forms for Field Supervisors
  • Community and Rehabilitation Evaluation Form.
  • School Counseling Evaluation Form
  • Student Affairs Evaluation Form