(Provide one copy of this form for Dr. Michael Russell, in EC 105 or by email, jmrussell@fullerton.edu,  and one for your requested supervisor.)

 

Name_______________________________    Phones____________________________________________

 

Street_____________________________        E-Mail____________________(PLEASE!)

 

City, State, Zip ___________________________

 

Student # (VERY IMPORTANT!)      ________________________Major__________________________________

 

Interviews scheduled with which instructors and when:   __________________________

 

Interview with Dr. Russell on ____________________

 

C & C day & time _______________  Semester_______________

               

Place a check in front of any of the following courses that you have already completed, and a P if the course is now in progress.

____HUSR 201, Intro. to Human Services                        When_____________ Instructor____________________ ____HUSR 300, Character and Conflict   Instructor             When_____________       Instructor____________________

___ HUSR 380 Theory & Tech. Counseling                      When _____________       Instructor __________________

____HUSR 396 (and 396L), Practicum                               When_____________       Instructor____________________

____HUSR 450, Theory & Prac.  Group                             When_____________      Instructor __________________

____HUSR 490, Group Leadership                                      When_____________       Instructor____________________

____HUSR 495, Fieldwork                                                   When_____________       Instructor____________________

____HUSR 496, Internship                                                  When_____________       Instructor____________________

 

List below other related Human Services courses, psychology courses, etc., you have completed or are taking presently,  as well as courses or groups you have had in which you were a member:

 

 

 

  

 

Have you ever been hospitalized or treated for severe emotional problems, or are there emotional, legal, or other factors that your instructor/supervisor would reasonably want to know about in considering your application?

 

 

 

 

On additional sheets of paper:

I.       Describe any experiences you have had in personal counseling (as a client) or any experiences you have had in personal growth workshops, training workshops, counseling groups, or relevant situations where you were a group member.  Discuss what these experiences have meant to you. 

 

II.  Describe other life experiences you have had (or related course work) that you think would help you in your work as a group leader, and explain how these are of value to you. 

 

III.   Say something about yourself in relation to why you want to enroll in group leadership, and something about  our assets and liabilities.  

 

 

 

 

 If you would like to be a group leader for a section of Character and Conflict (HUSR 300) in Fall 2006 you must arrange for an interview with the instructor, and also with Dr. Michael Russell

Provide each with copies of this application form.

 

Dr. Russell will conduct interviews in small groups, in H311-B on:.

            Monday, April 10, 2006, 2:30-3:30

            Tuesday, April 11, 2:00

            Wednesday, April 12, 10:00

            Thursday, April 13, 9:30

            Friday, April 14, 2006, 2:30

There may be other times, but try to work with these.  Just leave a message on your application form (left in EC 105) or by phone or by email stating which meeting you plan to attend, and assume you have an appointment at that time unless you are notified otherwise (so that I don’t have to call you back).  Call 714-278-2752 or email jmrussell@fullerton.edu.

 

Instructors and sections of Character and Conflict scheduled for Fall 2006 are:

Mary Franz                                                                                          on Mondays    4:00 -6:45 PM     Call 949-497-6767

Lynn Henning              on Tuesdays    4:00--6:45 PM    Call 714-505-3858

            Dr. Stuart Bloom          on Thursdays    1:00—3:45*   (This section is only for repeat         leaders doing this for no credit and not attending the weekend retreat.) 

Dr. Stuart Bloom          on Fridays 11:00—1:45 Call 949-497-6767

 If you are applying to more than one instructor, let them know that.

Those selected by a C & C instructor and by me MUST attend an ORIENTATION MEETING:  Thursday, May 4, 11:45—2:00, probably in the Women’s Center, UH 205.

 

Your time commitments in Fall would be:

1)      the Character and Conflict section in which you group-lead

2)      Supervision before and after

3)      Human Services 416 (1 unit) training retreat, August 18, 19, 20, 2006, Friday 9 a.m. through Sunday 4:00 p.m.,  in Laguna  Beach.     

4)      Human Services 490, with Dr.  Michael Russell W 4:00--6:45.

5)      Human Services 450, probably Wednesdays 11:00—2:00 with Dr. Jerry Corey.

6)      Time required for commenting on reaction papers

7)      Meeting with co-leader

While exceptions are made (e.g., for non-majors, graduate students), the  pre-requisites for HUSR 490  are: 

HUSR 201, HUSR 380, HUSR 396, HUSR 450, and consent of both the 490 instructor and the 300 instructor, who will be your supervisor.  If you have not yet had HUSR 450 when you group lead for the first time, you must take HUSR 450 concurrently.  Taking an additional practicum or internship in that same semester is discouraged.   HUSR 490 may be taken twice for credit. The first time 490 is typically used as a part of your 18 units of electives in your advisement track.  When taken a second time, you again register for 490 but need authorization from the Department Head (delegated to Dr. Russell) to use this in substitution for HUSR 495/495L, Fieldwork.  Note that HUSR 396 is supposed to be taken before HUSR 495, hence should be taken before using 490 in place of 495.  Using 490 in place of either 396 or 496 is strongly discouraged.   

All group leaders who attend the weekend retreat-- regardless of whether or why they take 490 – take HUSR 416, Group  Process and Membership (1 unit).    


 

At your interview you will be asked to sign a copy of this.  Keep this one for your records.

Waiver and Release of Liability

Human Services 416 and 490

 

I am planning to enroll in Human Services 416 (Group Process and Membership) and Human Services 490 (Practicum in Group Leadership).  The 416 class will meet from 9 a.m. on Friday, through 4:00 p.m., Sunday, of the weekend right before the start of regular classes.  It will meet at the home of Dr. Stuart Bloom, 1395 Cerritos Drive, Laguna Beach CA 92965.    This class and the 490 class are electives rather than required courses in the Human Services major.  The nature of these classes has been explained to me at meetings with supervisors and instructors, and I have had opportunity to raise questions or concerns I had about this. I am aware that the weekend consists of an experiential training workshop in group process, where we who are present will be learning about techniques and theories utilized in psychotherapy by actually applying these to ourselves.  I understand there will be topics which will focus on emotions and personal conflicts of my own as well as and others present, and that this will involve opportunities for me to learn about myself, and also about how groups function, by participating as a group member and as a group facilitator. There will be a similar experiential dimension to subsequent supervision meetings and classes.    I also understand that at this class, and throughout the semester in connection with this class, I will be experiencing techniques and topics common to counseling and psychotherapy, but that this is offered and undertaken for the objective of education rather than as diagnosis or treatment of psychological distress. I understand that I will be discussing personal topics about which I may feel conflicted or embarrassed or very emotional, with persons who may also be classmates or instructors of mine in other courses, or may have various sorts of roles or forms of interaction with these persons, and that these sorts of complex relationships may be confusing and are advised against by many therapist-educators.    I agree to respect the confidentiality of the disclosures of my classmates or supervisors, when these might be embarrassing to them.  I expect that what I disclose about myself will be held in confidence, but I understand that the supervisors cannot guarantee that my classmates will respect this confidentiality.  I understand that there are exceptions to confidentiality, where the instructors or supervisors may have an obligation to make appropriate reports on such matters as their belief that I may be a danger to myself or others, matters relating to potential child abuse, and matters where aspiring professionals or professionals in fields related to therapy seek appropriate professional consultation.   I understand the emotional nature of group process.  I understand that I am expected to be an active participant in this process. I agree to accept without dispute the judgment of the instructor(s) of this course should they advise me to discontinue participation.  I will not contest that recommendation.   In that event I expect that reasonable alternative means be made available for completing units in progress.  I understand that my instructors and supervisors in these classes are also educators who, guided by discretion, and with due respect for confidentiality, may draw from their experiences with classes such as these when they lecture or write.  While I am aware of the emotional focus of this course, I understand that supervisors provide time for purposes of education and not as part of any independent practices they may have.  I release them from responsibility for the level of care and commitment they might be expected to have if they were offering and I were seeking their services as therapists.   I understand that the setting of a private home rather than the University grounds is conducive to the objectives of this course, and also understand that a private residence will not have received the level of safety review I would expect of University facilities.  Further, I agree to indemnify the State for liability arising solely from my own tortuous acts or omissions, and I assume the risk of traveling to and from the site of the activity. In consideration of being allowed to participate in the above described activity I hereby release, hold harmless, and discharge the State of California, the Trustees of CSU, and all agents of CSUF from all claims, causes of action, or demands of any kind which I may have in the future regarding personal injury in connection with my participation in the above described activity, and similarly release, hold harmless, and discharge each and every instructor or supervisor of this activity and any person or party holding interest or ownership of property on which it is conducted.  I have read this Release, and understand the terms used in it and their legal significance.   I have been given an opportunity to ask questions about these matters in a meeting with the instructor.  This Release is freely and voluntarily given with the understanding that rights to legal recourse against the State and the instructor and supervisors are knowingly given up in return for allowing my participation in the activity described.