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: