PRACTICUM FIELDWORK CONTRACT
60 - Hr. Clinical Mental Health Counseling
Draw
up a typed contract that explicitly describes the agreement between y
ou the student, the supervisor, and the
site,
including:
•
Student’s name, address, and telephone number
•
The name, address and telephone number of the site
•
The clinical supervisor’s name and credentials
•
The contact person for the site, if different from the supervisor
•
The time commitment per week/per semester by the student
•
The supervision commitment by the supervisor
On-Site Fieldwork Contract
SITE
Name:
Address:
Phone Number:
Contact Person:
STUDENT
Name:
Address:
Home Phone:
Work Phone:
I, Student's Name:
, agree to provide approximately 100 hours o
f counseling-related
.
services as a Master’s-level fieldwork studentat the Site's Na
me:
during
the
four
-month
period
between MM/DD/YYYY
:
and MM/DD/YYYY:
.
During this time, I agree to become familiar with the policies and procedures of the
Site's Name:
. I will observe therapy, do co-therapy, and do
individual, group, and family therapy on my own as directed by my supervisor,
Supervisor's Name: . I also agree to be available to help with
any other therapy-related or educationally relevant experiences that would be helpful within the
constraints of the 100 hours. In all of my work, I will observe the established policies and
procedures of the Site's Name: .
I, Supervisor's Name: , agree to supervise Student's Name: , approximately
1 hour of individual supervision per week during the period between MM/DD/YYYY: , and
MM/DD/YYYY: . I will meet the responsibilities of a clinical supervisor as outlined in the
“Clinical Supervisor Responsibilities” form. This includes meeting one hour face-to-face per week,
regardless of hours Student's Name: , has spent with clients. To the degree that I am able,
I will try to structure Student's Name: , time so that he/she will have a minimum of 40
hours of face-to-face contact with clients. I understand that this contact can include co-therapy,
individual, group, and/or family therapy done by Student's Name: . In addition, I will
support Student's Name: , in conducting two taped sessions or provide & document
live supervision. I will complete periodic evaluations of Student's Name:
and, after discussing it with the student, will enter the evaluation into LiveText. I am aware
that I will need to have quarterly consultation via phone and/or email with the faculty
supervisor. I understand that the faculty member will provide Student's Name: , with group
supervision an average of 1.5 hours per week.
Supervisor Si
gnature
Date
Student Signature Date
