CEP Application for Practicum/Internship To receive permission to enroll, a new application is required for both the practicum and internship sequence. That is, you will submit 1 application for practicum and 1 application for internship. Summer and Fall applications are due March 1; Spring applications are due October 1. Applications should be typed, signed in pen, and stapled. Submission of this page (1) is not necessary. 1. HIPAA Certificate: (first application only) Complete the UMKC online Health Insurance Portability and Accountability Act (HIPAA) training/tutorial. After completing the training, print the certification email you will receive and submit it with your application. 2. Background Check a. School Counseling students must complete this step for the first practicum semester. The UMKC School of Education s Field Experience Coordinator, Dea Marx marxd@umkc.edu, will contact students who must complete the background check process again after the first practicum experience. Background check receipt: This is a copy of the receipt for the individual's FBI background check. The cost of a Missouri background check (as of March 19, 2012) is $44.80. Due to the length of time it takes to process, fingerprints must be submitted no later than March 1 st for the summer or fall semesters, and October 1 st for the spring semester, and the receipt must be submitted with this application. The initial background check must be processed through DESE (MO). Missouri: www.machs.mo.gov 4-digit Registration Number: 6692 Students are required to set up online profiles with DESE. If you already have an account with DESE, do not create another one or modify the existing account. Please follow the instructions at http://dese.mo.gov/divteachqual/teachcert/documents/helpdocument.pdf through the fourth paragraph (creating a profile). A Cleared or Not Cleared status will appear in the DESE profile and will be visible to Dea Bermudez. Dea will initiate a petition process for any School Counseling emphasis students who have a Not Cleared status. If the petition process does not produce a Cleared status by DESE, the student will not be eligible for the substitute teaching certificate, may not be eligible to complete practicum and internship experiences at school sites (individual schools or school districts make this decision), and may not be able to complete course requirements for the MA or EdS in Counseling and Guidance program School Counseling emphasis. If a School Counseling student is Not Cleared after the petition process, Dea will notify the student s program faculty who will communicate with the student. If, within the last twelve months, a student has completed a DESE background check for employment purposes, the student may submit a copy of that background check for division records. If there are no issues with the background check, it will fulfill the background check requirement. b. MA and EdS in Counseling and Guidance program Non-School Counseling emphasis students and PhD in Counseling Psychology students must complete a Missouri background check before submitting an application for their first practicum experience. Program faculty will review student background check results, and the student will be notified if any additional steps are required or if the student will be unable to complete the program course requirements. Sites outside of CCAS may require students to complete FBI background checks and/or background checks for other states. i. Before scheduling an appointment with the UMKC Police Department, pick up a card from the CEP Administrative Assistant in Room 215. Plan to take that card with you to the UMKC Police Department. ii. Schedule a fingerprinting appointment with the UMKC Police Department between 10:00am and 2:00pm Monday through Friday by calling 816-235-1515. The cost is $15 CASH for UMKC 1
students. Bring ID (driver s license or passport). Your fingerprints will be taken at 5005 Oak. You will receive a fingerprint card at the end of your visit. iii. Send the fingerprint card, a check or money order for $20 payable to State of Missouri, Criminal Record System Fund, and a Missouri State Highway Patrol Request for Criminal Record Check Form to the address listed on the form. On the Request for Criminal Record Check Form: 1. Complete the General Information section. In the Entity Type portion, choose State. In the Purpose for Request portion, choose Other and specify Fulfilling University Degree Program Requirement 2. In the Type of Record Check Processing Fee Method of Payment section, choose $20.00 Fingerprint Search 3. In the Send Reply To section, include the following information so that the results are sent to the Counseling and Educational Psychology Division Office: a. Telephone: 816-235-2492 b. Address: Administrative Assistant, UMKC School of Education, CEP, 5100 Rockhill Road, Kansas City, MO 64110. 3. Advisor's signature: An application may be left in the faculty advisor s mailbox for signature, but it is best if the student also sends an email to let the advisor know the application is there. The faculty advisor will sign the application if it seems to be complete and correct and submit the signed application to the Counseling and Educational Psychology Division Office. Either the faculty advisor or the Practicum and Internship graduate assistant will notify the student if anything is incorrect or missing. 2
UMKC Counseling & Education Psychology Division Application for Practicum/ Internship Date/Time Received for office use only *Effective Fall, 2017: you will only need to submit one application for both semesters of practicum, and one application for both semesters of internship. In other words, you will only need to submit two applications total. It is incumbent on the student to communicate any potential changes (e.g., extensions) in the course sequencing/practicum and internship experience to the practicum coordinator (Dr. Laurel Watson) and their advisor. Student Information NAME: Last First Middle Initial STUDENT ID: PHONE: UMKC EMAIL ADDRESS: PROGRAM/EMPHASIS AREA: Background Check/HIPAA HIPAA certificate new; attached on file Background Check new; receipt attached on file Please check the practicum/internship classes for which you are applying: (see prerequisites on next page) MA Semester/Year EdS Semester/Year Ph.D. Semester/Year 5531 5532 5531 5532 5533 (C&F only) 5532 5533 (C&F only) 5539 5631 5539 5575C 5639 5575A 5575B Site Name: *Note for PhD students: You will use this application solely for practicum. You may sign up for all practicum courses you intend to take per academic year (Fall, Spring, and if available, Summer semesters). In other words, you only need to submit one practicum application per academic year. However, should your circumstances change, it is your responsibility to inform your advisor and the practicum coordinator (Dr. Laurel Watson). Moreover, you will need to submit an off-site placement form for each practicum site and/or if your supervisor changes. Advisor s Printed Name Advisor s Signature Date 3
Please fill out the appropriate prerequisite section for your degree program, including the semester you took the course and the grade you received. Your advisor will then need to see this application and will review your coursework in Pathway to verify that you have met the prerequisite requirements. Complete the prerequisite section for your degree program only (MA, EdSpec, or PhD). *Note, we strongly encourage you to take CPCE 5503 (Psychopathology) prior or concurrently to 5531. MASTER S PRACTICUM AND INTERNSHIP PREREQUISITES & PLANNED ENROLLMENT: 1) Please choose the courses for which you are applying 2) Provide information for the corresponding prerequisite(s) only. Semester Grade CPCE 5531 Prerequisites: CPCE 5500 CPCE 5502 (School only) EDCI 5517 (School only) CPCE 5520 CPCE 5530 CPCE 5553 (may be enrolled concurrently) CPCE 5532 Prerequisites: CPCE 5531 CPCE 5533 (C&F only) Prerequisites: CPCE 5531 CPCE 5532 (optional) CPCE 5542 CPCE 5541 (may be enrolled concurrently) CPCE 5539 CPCE 5532 (MH or SC) or 5533 (C&F) CPCE 5575A Prerequisites: CPCE 5532 (MH or SC) or 5533 (C&F) CPCE 5575B Prerequisites: CPCE 5575A I have read the most recent version of the Practicum and Internship Handbook for Students, Instructors, and Supervisors and understand that I am responsible for the information contained in the handbook. Initials: By signing below, I affirm that I have completed the prerequisites for this course or will complete them prior to starting this course and that I have discussed my planned course enrollment with my faculty advisor. Student Printed Name Student Signature Date 4
EDUCATIONAL SPECIALIST PRACTICUM PREREQUISITES & PLANNED ENROLLMENT: 1) Please choose the courses for which you are applying 2) Provide information for the corresponding prerequisite(s) only. Semester Grade CPCE 5532 (General MH or School) Prerequisites: CPCE 5500 CPCE 5502 (School) EDCI 5517 (School) CPCE 5520 (or equivalent) CPCE 5530 (or equivalent) CPCE 5553 (or equivalent; may be enrolled concurrently) CPCE 5533 (C&F) Prerequisites: CPCE 5531 (or equivalent) CPCE 5542 CPCE 5541 (may be enrolled concurrently) CPCE 5539 (General MH) Prerequisites: CPCE 5532 (General MH) CPCE 5575C (School) Prerequisites: CPCE 5532 (School) CPCE 5633 (C&F) Prerequisites: CPCE 5533 (or equivalent) CPCE 5542 (or equivalent) I have read the most recent version of the Practicum and Internship Handbook for Students, Instructors, and Supervisors and understand that I am responsible for the information contained in the handbook. Initials: By signing below, I affirm that I have completed the prerequisites for this course or will complete them prior to starting this course. Student Printed Name Student Signature Date 5
Ph.D. PRACTICUM PREREQUISITES & PLANNED ENROLLMENT: 1) Please choose the courses for which you are applying, 2) Provide information for the corresponding prerequisite(s) only, *Note, we strongly encourage you to take CPCE 5503 (Psychopathology) prior or concurrently to 5531. Semester Grade CPCE 5531 Prerequisites: CPCE 5600 CPCE 5520 CPCE 5530 CPCE 5532 Prerequisites: CPCE 5531 CPCE 5533 (C&F) Prerequisites: CPCE 5531 CPCE 5541 (may be enrolled concurrently) CPCE 5542 CPCE 5631 Prerequisites CPCE 5532 CPCE 5639 Prerequisites: CPCE 5631 CPCE 5632 Prerequisites: CPCE 5540 CPCE 5633 Prerequisites: CPCE 5542 I have read the most recent version of the Practicum and Internship Handbook for Students, Instructors, and Supervisors and understand that I am responsible for the information contained in the handbook. Initials: By signing below, I affirm that I have completed the prerequisites for this course or will complete them prior to starting this course. Student Printed Name Student Signature Date 6
OFF-SITE PLACEMENT FORM Submission Deadline for Summer and Fall Practicum/Internship Experience: Submission Deadline for Spring Practicum/Internship Experience: April 30 th November 30 th Please type or print legibly Student Name MA Semester/Year EdS Semester/Year Ph.D. Semester/Year 5531 5532 5531 5532 5533 (C&F only) 5532 5533 (C&F only) 5539 5631 5539 5575C 5639 5575A 5575B Site Name: Site Information Site Name Site Address Street City State Zip School District (school sites only) Supervisor s Name Title (Dr., Ms., Mr.) First Last Supervisor s Credentials (e.g., Certified School Counselor CSC, Licensed Psychologist PhD, Licensed Professional Counselor LPC) Supervisor s Site Address Street 7
City State Zip Supervisor s Phone (Day) (Evening) Supervisor s Email Address Students completing a practicum or internship experience cannot receive third party reimbursements nor shall an agency receive third party payments based on the student s work except for testing at the doctoral level. PRIVATE PRACTICE CONTRACT: If the internship will take place in a private practice setting, you will need to provide a contract of the experiences you will have in addition to seeing clients (e.g., attending workshops, lectures, readings). You need to list these experiences below and have them approved by your supervisor and faculty advisor prior to starting your practicum. Please complete this form, including student, site supervisor, and faculty advisor signatures. When completed, submit this form and provide a brief statement of why you chose to do a private practice setting to your advisor (who will then bring it to the faculty for approval). 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Student Printed Name Student Signature Date Site Supervisor Printed Name Site Supervisor Signature Date Faculty Advisor Printed Name Faculty Advisor Signature Date 8
RELEASE AND HOLD HARMLESS AGREEMENT CURATORS OF THE UNIVERSITY OF MISSOURI AND UNIVERSITY OF MISSOURI KANSAS CITY Please read the following carefully. If you have any questions, please have them answered before signing this document. I,, in consideration of the opportunity to participate in practicum or internship, as (student name) A new, signed copy must be submitted with each application. part of the fulfillment of the requirements for, do hereby release, waive, and (course number, ex: CPCE 5531) hold harmless The University of Missouri, its curators, officers, agents, and employees, from and against any and all claims, demands or causes of action of any type whatsoever, including property damage, personal injury or death, arising out of or in any way related to my participation in the practicum or internship activities for the course stated above. I am aware that there are risks and dangers associated with my participation in practicum or internship efforts, including the risk of property damage, personal injury or death. I understand that I may be in areas with higher than average crime rates where violent crime occurs. I assume full responsibility for any injuries or damages I may sustain as a result of my participation, including while traveling to or from practicum or internship sites. I understand that I am solely responsible for any medical costs I may incur as a result of my participation practicum or internship activities. I acknowledge that the practicum or internship experience described above does not create an employee/employer or independent contractor relationship with The University of Missouri or with any entity where I am placed and that I will not receive, cannot accept or claim entitlement to any wages, benefits, workers compensation or any other form of compensation. I understand that the University may not provide any Accident or Medical Insurance. This agreement is binding, upon the members of my family, spouse, my estate, heirs, administrators, personal representatives, assigns and any other person entitled to act on my behalf. This agreement shall be construed under the laws of Missouri. I have read and understand the terms of this Release and Hold Harmless Agreement and agree to all terms and conditions. I am of lawful age (above 18 years old) and legally competent to sign this waiver and release, and I have signed this document as my own free act. Participant s Full Name Participant s Signature Date 9 This form is required for the first semester of practicum or internship only and will be applicable to all future practicum or internship experiences during the completion of the degree program.
Student Background Check Requirement & Release of Information Students in the UMKC School of Education s Counseling and Educational Psychology Division are required to obtain and provide verification of a current criminal background check as a condition of participating in any clinical experience in the Counseling Psychology or Counseling & Guidance programs at the University of Missouri-Kansas City, including practica at Community Counseling and Assessment Services. Verification must be provided prior to the student's assignment at an affiliated school or institution. By signing this document, I give the UMKC School of Education s Counseling and Educational Psychology Division permission to release any information requested by the School of Education faculty and/or to the agency in which I may have practicum or internship experiences. This information may include but is not limited to my name, social security number, telephone number, and disclosure of results from background checks. Additional information may be released as requested by agencies. The school or agency maintains the right to deny a student to participate in a clinical experience if the student refuses to release the results of the background check, or if a background check reveals a conviction related to the items listed below. In such cases, the inability to place a student in a clinical setting would prevent the student from completing the program. Failure on the part of a student to submit to a criminal background check will delay progression or render the student unable to complete the professional degree program. The Counseling and Educational Psychology Division faculty may review information received from a student s background check at any time. If the faculty decides that an offense found in the background check is problematic (e.g., relevant to professional and ethical standards and the conditions described in the paragraph following) the faculty may take action. Such actions could include (a) asking the student for an explanation of the offense and actions taken to remediate; (b) delay in beginning practicum; or (c) in extreme cases, termination from the program (e.g., when the offense is particularly serious and relevant to clinical activity, or when as a result a student seems unlikely to secure practicum placement, internship, or eventual licensure). The Missouri Revised Statutes Section 337.525 outlines grounds for refusal to issue or renew a license for professional counselors. Observing these guidelines, the Counseling Psychology and Counseling & Guidance programs at UMKC advise students that clinical experiences may not be made available if they are convicted of, or have entered a plea of guilty or nolo contendere under the laws of any state or the United States to: Any offense reasonably related to the qualifications, functions, or duties of a professional counselor/psychologist. Any offense of which an essential element is fraud, dishonesty, or an act of violence. Any offense involving moral turpitude, whether or not sentence is imposed. I have read and understand the UMKC Counseling and Educational Psychology Division background check requirement and do agree to the release of information as stated above. Printed Name Signature Date 10