Completion of Advanced Practicum Form – William Glasser Institute Ireland

This form is to be completed by an Advanced Practicum trainee at the end of the Practicum. Please complete this form and send it by clicking SUBMIT.

Name *

First

Last

Address *

Town/City *

Contact Phone Number *

Email *

Basic Intensive Course Dates *

Basic Intensive Course Instructor *

Basic Practicum Supervisor *

Advanced Practicum Supervisor *

Advanced Practicum Dates *

Advanced Praticum Course Code

You can obtain this code from your advanced supervisor.

APPLICANT'S SELF-EVALUATION: I have successfully completed the requirements of the Advanced Practicum and believe I am ready to attend my Certification Course. *

1. Specific area(s) in which I describe my performance as quality. *

2. Specific areas in which I believe I need to improve the quality of my performance are detailed above. *

I believe I am ready to attend the Certification Course for the following reasons: *

Name as signature *

I provide my full name above as my signature to this form.

DATE *