Full Name __________________________________________________________________

Student ID # ______________________________________________________________

Address ______________________________________________________________________

______________________________________________________________________________

Home Telephone ___________________________________

Work Telephone____________________________________

E-mail _______________________________________________

Teletechnet Site Location ___________________________________Site #________________

Course sequencing requirements have been carefully worked out to provide students with an educationally-sound and developmentally-planned curriculum. Any departure from the usual sequence is discouraged and must be approved by the Human Services Program Coordinator, and then only for truly exceptional cases and for academically (GPA>3.0) and otherwise strong students. Often, students who are in a haste to graduate and leave the University are the very ones who need slowing down. Further, any extra burden on the student during the internship violates the internship experience and is, thus, questionable practice.

With the above stated, it is clear that from time to time there may be a student who is capable and doing well in the program and who can carry one extra course during the internship. The following are the guidelines for granting an exception. Only one course (minor/cluster or HS) can be taken at the same time as the internship; the core courses (COUN 339, 341, 343, 346, & 444) must never be taken during or after the internship. COUN 344, 447, 448, or 491 will be permitted only with the Human Services Program Coordinator’s approval and with a signed letter or memo from the student attached to the Form, stipulating that he/she will not during the internship undertake any helping responsibilities which are of their nature connected to the material of the course; this means that the student taking the career course must not do career development work during the internship, the student taking the addictions course not do addictions treatment, and so forth).

Semester when internship is planned ________________________________________________

Human Services or general education course to be taken during internship_______________________

Human Services course to be taken after internship_________________________________________

Student's current GPA____________________

If the course is COUN 344, 447, 448, or 491, is there a signed letter or memo from the student attached to the Form, stipulating that he/she will not during the internship undertake any counseling responsibilities which are of their nature connected to the material of the course? Yes___No ___
_________________________________________________________________________________

Brief rationale for exception: _________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Approved (Site Director Signature): ______________________________________Date ________

Approved (Coordinator Signature): _______________________________________Date _______

(This form to be placed in the student's file; student to be notified of action via university e-mail account.)


NOTE: Submission of this form does not guarantee approval.