INTERNSHIP FIELDWORK CONTRACT
0-Hr. Clinical Mental Health Counseling
Draw up a typed contract that explicitly describes the agreement between you the student, the supervisor, and the
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
Off-Site Fieldwork Contract
I, Student's Name: agree to provide approximately 600 hours of counseling-related
services as a Master’s-level fieldwork student at the Site's Name:
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 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,
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 him/her, 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.
, as the site director of Site's Name: ,
to release confidential information
I, Site Director's Name:
agree to give permission to Student's Name:
to Off-Site Supervisor's Name: .
Supervisor's Signature: .
Site Director's Signature: .
Student's Signature: .