60-Hr. Professional Counseling
Draw up a typed contract that explicitly describes the agreement between you 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
Phone Number:
Contact Person:
Home Phone:
Work Phone:
I, Student's Name:
, agree to provide approximately 600 hours of counseling-related
services as a Master’s-level fieldwork studentat the Site's Na
between 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 600 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 240 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, I 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 Signature
Student Signature Date