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St. Cloud State University

St. Cloud State University

Forms / Applications

CPSY 445, 446 (Chemical Dependency Internship)
Request for Permission to Enter

Complete this form at least TWO semesters in advance of planning to take this course in order to graduate on time. It is your responsibility to update the information on this form each semester in advance of being assigned to this class. Do this on-line by filling out the form again.

An orientation for internship will be held early each semester. After the orientation, contact the internship instructor listed in the course schedule for assistance in locating an internship site.

Today's Date
(mm/dd/yyyy)
Name
S.S.N. or Student ID
Background Information
Is CPSY your major? Yes No
Is Chemical Dependency your major? Yes No
(Note: If CD is your major, contact Dr. Vesely about internship requirements and sites.)

Total semester credits you have completed including this semester:
Total number of classes you need to graduate AFTER the end of this semester:
What is your status? Junior Senior
Preparation Classes
  Semester Grade Instructor
CPSY 419 Professional Ethics
CPSY 327 Group Process OR
CPSY 434 Behavior Analysis II
CPSY 444 Internship Prior or current
CPSY 445 Internship Prior or current
Request
I request to take internship for (semester) of (year).
Second Choice: (semester) (year)
Planned Graduation Date: (semester) (year)

Any Special Concerns?
Contact
Phone
E-mail

The CPSY office will e-mail you when you have permission to register. You then register through on-line registration. Please register in a timely manner.