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First Name*

Last Name*

Street Address*

City*

State*

Zip*

Phone Number*

By providing a telephone number and submitting this form you are consenting to be contacted by SMS. Message frequency varies. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.

Email*

Date of Birth*

Have you ever been convicted of a criminal offense or been listed on the misconduct registry?*

Yes
No

Are you or any family members receiving services at TCC?*

Yes
No

Have you lived outside the state of Texas in the last two years?*

Yes
No

Days Available (choose all that apply)*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Preferred Hours (choose all that apply)*

Mornings
Afternoons
Evenings

Program of Interest*

Practicum
Post Graduate Internship (LPC-A, LMSW-In LCSW Internship, LMFT-A)

Current Level of Education*

Undergraduate
Graduate

School

Program/Major

Field of Interest

Semester/Dates of Interest

Please provide name of preceptor (if applicable)

Do you speak any other languages other than English?

Yes
No

If yes, what language(s)?

Are you a current Employee?

Yes
No

Number of Hours Required

Beginning and end dates of semester

We will only provide supervision for a minimum of 2 semesters as the time commitment required puts a strain on Center resources.

I understand that I will be held to the highest professional standards while in this practicum/internship. I acknowledge that I have answered all questions truthfully and to the best of my knowledge. By clicking on submit, I understand that I will also be required to pay for my required CPR/First Aid training (cost is $24.00) and maintenance CPR training BEFORE beginning this internship experience. If at any time I am unable to complete my requirements, I understand that the Center reserves the right to cease my internship/practicum immediately and will notify my institution immediately.

24 Hour crisis line | Línea de crisis: (877) 277-2226 or dial 911

TCC Practicum & Intern Application

Main Office:

Monday-Friday

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