George Mason University
Clinical Mental Health Counseling (CMHC) P&I ChecklistStudent Information:NameStudent G #AddressGMU Email PhoneInstructions to Student: Utilize this form to keep track of your required P&I paperwork. Fill in the required information and turn this form in along with your Initial Application. The Clinical Practice Specialist can indicate receipt of your documents below if needed.Date ReceivedItem DueDue Date (Fall / Spring / Summer Prac Start)Item to be Submitted by Student to:Appointment with faculty advisor to discuss P&I plans and applicationOne semester prior to submitting online initial Prac applicationFaculty AdvisorOnline Initial Application & Supporting Documents (Unofficial Mason Transcript; Program Planning Sheet, and P&I Checklist)February 15 / September 15 / February 15Clinical Practice Specialist Two copies of Site Approval FormJuly 15 / November 15 / April 15Counseling Program Clinical Coordinator Two copies of Site Supervisor Resume/CVJuly 15 / November 15 / April 15Counseling Program Clinical CoordinatorCopy of Liability Insurance (valid through Prac & Intern I/II) First day of PracPrac University SupervisorPracticum/Internship Supervision AgreementThree weeks after start of PracPrac University SupervisorPrac Final Log of HoursOne week after end of PracPrac University SupervisorPrac Final Evaluation by On-Site SupervisorLast day of Prac classPrac University SupervisorTerm Break Agreement for post-Prac (optional)One week after start of Intern IIntern I University SupervisorIntern I Final Log of HoursOne week after end of Intern IIntern I University SupervisorIntern I Final Evaluation by On-Site SupervisorLast day of Intern I classIntern I University SupervisorTerm Break Agreement for post-Internship I (optional)One week after start of Intern IIIntern II University SupervisorIntern II Final Log of HoursOne week after end of Intern IIIntern II University SupervisorIntern II Final Evaluation by On-Site SupervisorLast day of Intern II classIntern II University SupervisorSite Feedback Form (print out of online survey) only completed once if same site for all three semestersLast day of Intern II classIntern II University Supervisor ................
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