Clinical Mental Health Counseling Application Form

Section I: Personal Information
First Name:
Middle Name:
Last Name:
Preferred Name:
Sex:
Address:
City:
State:
Zip:
Home Phone :
Work Phone:
Cell Phone:
Email:
Social Security Number:
Date of Birth :
Country of Birth:
Have you ever attended LaGrange College?
 If yes, when:
Are you a veteran:
 If yes, do you plan to use the G.I. Bill:
Your response to this section is voluntary.
The following information is requested for statistical purposes to the U.S. Department of Health and Human Services.
Race:
Religious preference:
Marital Status:
 
Section II: Educational Background: Please list all colleges and universities you have attended.
Institution:
City and State:
Dates Attended:
Degree and Major:
Graduated:
  
Institution:
City and State:
Dates Attended:
Degree and Major:
Graduated:
  
Institution:
City and State:
Dates Attended:
Degree and Major:
Graduated:
  
Section III: References: List the name of the three personal references who will be sending letters of recommendation on your behalf:
 NameEmail Address
Reference 1:
Reference 2:
Reference 3:
   
Section IV: Letter of Recommendations Waiver
Under the Federal Family Educational Rights and Privacy Act of 1974, students are entitled to review their academic records, including letters of recommendation. However, those assessing the recommendations, and those writing the recommendations, may attach more significance to the recommendations if they remain confidential. Applicants must decide whether their recommendations will remain confidential or not.

Please indicate your choice below:

I waive my right to review the recommendations and I prefer the recommendations  remain confidential.
I do not waive my right to review the recommendations.  

 How did you hear about Clinical Mental Health Counseling at LaGrange College? 
I certify that the information given on this application is complete and correct to the best of my knowledge, and that I have attended no other institution other than those listed. I understand that I am responsible for the forwarding of records from all schools I have attended, and that such transcripts become the property of LaGrange College and will not be returned to me.
   
Important dates
  • Applications from LaGrange College students and Point University students received before February 10, 2017 will be eligible for our early interviews on February 16, 2017.
  • Applications received before April 14, 2017 will be eligible for our spring interviews on April 20, 2017.
  • Applications received before July 7, 2017 will be eligible for our summer interviews on July 13, 2017.
  • Applications received after the summer interview date will be eligible for the 2018-2019 cohort.





A complete application includes:

  1. Application Form
  2. Curriculum Vitae
  3. Statement of Purpose
  4. Letters of Recommendation
  5. All official undergraduate and graduate transcripts
  6. Official GRE or MAT score reports

To begin, please complete the Application form and select Submit.

If you have any questions, please contact counseling@lagrange.edu