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College of Education - Louisiana Tech University


M.A., Counseling & Guidance

Forms

Student Forms

These forms are primarily administrative forms primarily intended for student use. Included are application forms, log forms, summaries, and other forms intended for academic record-keeping.

Checklist Checklist of steps to complete the practicum/internship portfolio.
Student Data Form Informational form to be filed prior to the beginning of practicum or internship to report the practicum site, site supervisor, schedule, and other relevant information.
Monthly Log Form for tracking weekly practica/internship activity, to be filed monthly.
Application Application for acceptance into practica/internship.
Resume Form Filed upon resuming practicum/internship work.
Quarterly Summary Summary of data compiled in the monthly log, to be completed on a quarterly basis.
Site Evaluation Student-submitted evaluation of their practica/internship site, to be completed at the conclusion of their placement.
Portfolio Evaluation Rubric Evaluation rubric to be used in the evaluation of student portfolios.

Client Forms

These forms pertain to and/or should be primarily be completed by the client. Please note that some information gathered by these forms may be considered confidential, and subject to Federal and State laws governing client privacy.

Adult Consent Form Consent form establishing the agreement of the client to counseling and to establish fundamental understanding on issues of session recording and confidentiality. To be read and signed by adult clients age 18 and above at time of intake.
Minor Consent Form Consent form establishing the agreement of the client to counseling and to establish fundamental understanding on issues of session recording and confidentiality. To be read and signed by the parents or legal guardian of minor clients ages 17 and below at time of intake.
Disclosure Statement Disclosure notice to be provided to clients at time of intake. Form establishes that clients have been notified that the student is a counselor trainee, that information may be anonymously shared with professional peers and supervisors, and legal restrictions on confidentiality.
Intake Form Form to be filled out by clients at time of intake to collect biographical and background information.
Mental Status Assessment Exam used to assess the mental state of the client. To be completed by the counselor.
Counseling Session Notes Form used to guide the collection of client session notes. To be completed by the counselor at each session.
Suicide Consultation Form Specific form to be completed by the counselor for potentially suicidal clients. This information should be given to the counselor's supervisor to collaborate on a treatment plan and placed in the client's record.
Suicide Contract Contract to be used for potentially suicidal clients. The client will agree not to commit suicide, rest well, remove harmful objects, and to contact their counselor immediately if they are suicidal.

Site Forms

Administrative forms to be completed by practicum and internship sites and site supervisors.

Site Approval Request Form requesting approval for assignment of a student to a particular site.
Memorandum of Agreement Memorandum of Agreement between the student, University, and site.
Statement of Supervisor's Qualifications Biographical and professional profile to be completed by the site-supervisor.
Clinical Skills Assessment Rubric Rubric to be utilized by supervisors in assessing students' clinical skills.
Counseling Trainee Evaluation (Site Supervisor) Counseling trainee evaluation form to be completed by the trainee's site supervisor at the conclusion of their practicum/internship.
Counseling Trainee Evaluation (Faculty Supervisor) Counseling trainee evaluation form to be completed by the trainee's faculty supervisor at the conclusion of their practicum/internship.
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