Practicum/Internship Site Approval FormAgency Information

Agency Name:

____________________________________________________________________________

Population Served:

_________________________________________________________________________

Services Provided:

________________________________________________________________________

Agency Contact: _________________________________ Phone #: ____________________

Address:

_____________________________________________________________________________

Hours of Operation:

________________________________________________________________________

Designated Site Supervisor(s)

Name: ___________________________________ Title: _______________________

Phone #: _________________________ Email: __________________________________

Highest Academic Degree: _________________ Licensure/Certification: ______________

Name: ___________________________________ Title: _______________________

Phone #: _________________________ Email: __________________________________

Highest Academic Degree: _________________ Licensure/Certification: ______________

Practicum/Internship Program Information

Types of Supervision provided:

____________________________________________________________________________

Education/Training provided to students:

____________________________________________________________________________

Direct Service Opportunities:

____________________________________________________________________________

Indirect Service Opportunities:

____________________________________________________________________________

Totals Hours students can expect weekly:

____________________________________________________________________________

Requirements/Agreements Checklist

_______ The site has a designated Practicum/Internship supervisor who has appropriate credentials, time, and interest for training the practicum student, as well as

a. a master’s degree in counseling or a related professionb. at least two years of pertinent professional experiencec. counseling supervision training and experience.

_______ The site has opportunities for the student to engage in a variety of counseling activities under supervision and for evaluating the student’s performance

_______ The site will provide the student with adequate work space and materials to conduct professional activities;

_______ The site will provide supervisory contact that involves some examination of student work using audio/visual tapes, observation, and/or live supervision; and

_______ The site will provide written midterm and final evaluations of student based on criteria established by the university program.

_______ The site supervisor will be available for contact (email or phone) with Practicum/Internship professor as needed______ (1) hour of direct supervision will be provided to student (individual/triadic)

Primary model of supervision used: ____________________________

_______ The site allows session recording via audio or video for evaluation purposes and/or live supervision by faculty (with client consent)

Process for students who may be interested in site:

Description of site to be placed in approved site list for students to view: