Completion of Basic Practicum Form – William Glasser Institute Ireland

This form is to be completed by a Basic 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 Dates *

Basic Practicum Supervisor *

Basic Praticum Course Code

You can obtain this code from your supervisor.

APPLICANT'S SELF-EVALUATION: I have successfully completed the requirements of the Basic Practicum and believe I am ready to attend my Advanced Intensive 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 Advanced Course for the following reasons: *

Name as signature *

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

DATE *