UW-Madison - Department of Counseling Psychology - PhD Forms and Resources

Medical imaging Carillon Tower Glass blowing Laptop and lecture A smiling student Sunrise over the Education Building Chairs on the Memorial Union Terrace Bascom hall staircase Graduating students in silhouette Crowd of people on Bascom Hill A student tutoring Student with diploma Dance Department performance Night view of Bascom in the winter Memorial Union Terrace in autumn Memorial Union Terrace chairs Dance department performance Bucky Badger in front of a parade float Bascom Hall in the summertime Lincoln statue Students walking in the snow University of Wisconsin - Madison Crest Lincoln statue in the snow Forward Logo Student at graduation Bicycle in the snow Rathskellar Fireplace Sailboat with Capitol Building in the background A sailboat at the Memorial Union Bascom Hill in Autumn Bucky Badger studying with a student. Students among blooming trees at UW-Madison Bucky reading a book University flag on Bascom Hill Video camera view screen Student on a frozen lake Lincoln Statue on Bascom Hill Bascom Hill in winter Students collaborating Memorial Union Terrace chairs in the snow Kohl Center logo Graduates with diplomas A hands-on project Stacked, illuminated figures View from the top of Van Hise


Main Office

Department of
Counseling Psychology

School of Education
335 Education Building
1000 Bascom Mall
MadisonWI  53706-1326

Tel: 608/262-4807
Fax: 608/265-4174

Email: counpsych@education.wisc.edu
or by contact form

Ph.D. Program Forms and Professional Resources

Program Forms

For students who wish to petition for a program variance, please initiate the petition with their advisors. A written petition secures a place on the closed portion of the next faculty meeting. The results of the faculty action are recorded in the faculty meeting minutes. A copy of the minutes is also placed in the student's file.


  • Student Program Worksheet pdf | Word

Evaluation of Practicum Readiness

  • Evaluation of Ph.D. Student by Department Faculty for Practicum Readiness pdf | Word

Verification Forms

  • Handbook Verification Form pdf | Word
  • Ethics Verification Form pdf | Word

Doctoral Student Report on Progress

  • Doctoral Student Report on Progress pdf | Word
  • File Audit Form pdf | Word
  • Individual Development Plan pdf | Word

Practicum Forms: Foundational and Advanced

  • Evaluation of Practicum Student by Supervisor pdf | Word
  • Student Evaluation of Supervision pdf | Word 
  • Statement of Clinical Accountability Form pdf | Word
  • Statement of Monthly Clinical and Supervision Hours pdf | Word

Preliminary Examination

  • Evaluation of Preliminary Examination Part 1: Clinical Case pdf | Word
  • Evaluation of Preliminary Examination Part 2: Supervision Case pdf | Word
  • Dissertation Proposal Request Form pdf | Word (submit 4 weeks prior to the Dissertation Proposal)
  • Evaluation of Preliminary Examination Part 3: Dissertation Proposal pdf | Word
  • Preliminary Examination Dates

Advancement to Dissertator Status

  • Ph.D. Minor Agreement Form pdf | Word
  • Request for Advancement to Dissertator Status pdf | Word


  • Externship Application Plan pdf | Word
  • Statement of Clinical Accountability Form pdf | Word
  • Evaluation of Externship Student by Supervisor pdf | Word


  • Internship Application Plan pdfWord
  • Internal Verification of Internship Readiness pdf | Word

Ph.D. Defense

  • Dissertation Defense Request Form pdf | Word

Program Administration

  • Program Approval Form - Advisor Approved Actions pdf | Word
  • Program Approval Form - Faculty Approved Actions pdf | Word
  • Change of Advisor Form pdf | Word
  • Secondary Practicum Agreement Form and Site Information  pdf | Word
  • Department Sanctioned Non-practicum Clinical Experience Application Plan pdf | Word
  • Grievance Procedure​  

Remediation Plan: Development Guidelines

  • Remediation Plan Development Guidelines pdf | Word

​decision tree

  • ​Decision Tree pdf

Institutional Review Board (IRB) Forms

All students in the department conducting research is required to complete an on-line tutorial program and and complete an IRB protocol prior to beginning research.

Criminal Background Forms

© 2020 Board of Regents of the University of Wisconsin System • Privacy Notice • Please contact the School of Education External Relations Office with questions, issues or comments about this site.