INTERNSHIP FIELDWORK CONTRACT
6
0-Hr. Clinical Mental Health 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
Off-Site Fieldwork Contract
STUDENT
Name:
Address:
Home Phone:
Work Phone:
SITE
Name:
Address:
Phone Number:
Contact Person:
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,
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 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: .
Date: .
Site Director's Signature: .
Date: .
Student's Signature: .
Date: .
