VERIFICATION OF PERSONAL COUNSELING - California State University ...
Counselor Education Program Department of Educational Psychology & Counseling
18111 Nordhoff Street Northridge, CA 91330-8265
818/677-2599
VERIFICATION OF PERSONAL COUNSELING
The signing of this form certifies that the student listed below has completed a minimum of six hours of individual counseling/therapy with the counselor/ therapist listed below during the time period in which s/he has been registered in EPC 659A/B - Practicum at California State University, Northridge.
Name of Student (please print):
Name of Counselor/Therapist (please print):
Address
Phone(s)
Is counselor an advanced (second or later) year Master's student?
Yes
No
If not a Master's student, please list professional title, type of license, and/or license number below:
Date counseling/therapy began: Date counseling/therapy ended: Total number of sessions in this time period:
Signature of Student
Signature of Counselor/Therapist
FW-659A/B, MAS (12/01)
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