1
INTERNSHIP FIELDWORK CONTRACT
60-Hr. Marriage and Family Therapy
48-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
SITE
Name:
Address:
Phone Number:
Contact Person:
STUDENT
Name:
Address:
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
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 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:
.
I will complete periodic evaluations of Student's Name: and, after discussing
it with the student, I will provide the student with the original to submit into Blackboard. I am aware
that I will speak with the faculty supervisor at least once per term.
Supervisor Signa
ture
Date
Student Signature Date