EDCO 389 Counseling Internship Checklist of Forms/Assignments

The list below includes all of the forms and assignments for the Internship experience. All of the items on this list are due in a packet submitted to the instructor at the end of each semester (unless otherwise indicated below). See Instructions for Checklist of Forms/Assignments for more information about these forms and submission requirements. (Download Checklist (PDF))

Date Submitted
Student Name




Form #1 - Internship Application (Only required prior to first semester. Indicate date submitted. Application does not need to be included in end of semester packet.) PDF


Form #2 – Internship Placement Contract (Due prior to semester/start at placement. Staff must have a current Contract for each semester student is at placement. Please see CP staff to see if this form needs to be re-submitted during current semester. Indicate date discussed with staff. Include copy of Contract in packet at the end of the semester.) PDF or MS Word

  Intern Behavior Contract (Signed and submitted by the student prior to the start of the a new academic year or new site.) PDF

Supervisor Contract (Signed by the site-supervisor and submitted to the faculty supervisor/staff at the start of the semester.) PDF


Proof of Insurance   (This must be submitted by student prior to working on site. Insurance must be valid for all of the semesters that student is working on site.)


Form # 3 -Internship Competency Checklist (Note: there are separate forms for MH and SC Internships. The Competency Checklist should be completed by site supervisor.) SC PDF, SC MS Word; MH PDF, MH MS Word


Form #4 - Student Evaluation of Internship Site (Completed by student.) PDF or MS Word


Form #5 - Student Evaluation of Site-Supervisor (Completed by student.) PDF or MS Word


Form #6 - Site-Supervisor’s Evaluation of the UVM Counseling Program (Completed by site-supervisor.) PDF or MS Word


Internship Accountability Form (Completed by student. Original form [available from staff] must be used. All hours must match final Log of Hours. All signatures must be on form at time of submission. Student should retain copy of this form.) PDF or MS Word


Hour Logs (Hour logs for semester must be submitted at the end of the semester. Student should keep copies.) Excel


Case Presentation (Does not need to be submitted in packet. Indicate date completed in class.)


Referral Log (Submit to instructor –does not need to be included in packet. Indicate date submitted.)


Reading List (Submit to instructor –does not need to be included in packet. Indicate date submitted.)


Dates of Site Visit(s) (Indicate: Site Visit/Phone Contact)








Instructions for Internship Forms

Each Internship student is responsible for submitting the Checklist of Forms as the cover-page for the packet of forms submitted to the faculty supervisor/instructor at the end of each semester of Internship. Students must indicate the date of completion/submission of each requirement on the checklist. Grades will not be issued and recommendation for licensure will not be processed without the Checklist of Forms completed and accompanying all original forms. All are required to be submitted by the due date given by the instructor.

When submitting final Internship paperwork, all work should be included in a packet as indicated below:

Checklist of Forms

Form 1

Form 2

Intern Behavior Contract Signed and submitted by the student prior to the start of the new academic year or at a new site.

Proof of Insurance

Form 3

Form 4

Form 5

Form 6

Accountability Form

Hours Log