This form must be completed and returned to the MSU Counseling Psychology Program Director immediately after an internship offer has been accepted.  The student should also request that the Director of Training at the internship site send a copy of the acceptance letter, listing conditions of the appointment, to the MSU Program Director.  Finally, the MSU Program Secretary should be given the intern's local forwarding address at the internship location when this information becomes available. 
 

Name:                                                                         Student Number:                        
 

Internship Site and Address:                                                                                   

Date of Placement: Start                                                        Complete                              
 

Internship Director of Training: Name                                                   

                                               Phone Number