LOUISIANA COLLEGE
MSW Program
Agency Information Form
Agency: __________________________________________________________________________________
Address: _________________________________________________________________________________
_________________________________________________________________________________
Telephone: _________________________________________________________________________________
E-mail Address _________________________________________________________________________________
Agency Director: __________________________________________________________________________
Designated Field Supervisor: ___________________________________________________________________
Designated Field Task Supervisor: ___________________________________________________________________
Please identify the clientele served by the agency (individuals, families, groups, communities, and
or organizations). Please state all that apply and how you will provide the above learning experiences for
the student.
Is your agency considered to be a healthcare or behavioral health service provider?
Stipends, Paid Internships, Employment Based Experience:
Does your agency offer any funding options for students while in field practicum?
Pre-Field Requirements:
Does your agency require students to complete an agency application, student orientation, TB test,
background checks, etc. prior to beginning field? Please state them below.
Designated Field Supervisor (Name and Credentials):
Signature: ___________________________________ Date: ___________________
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