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:
I, Student's Name:
, agree to provide approximately 300 hours of counseling-related
, during
services as a Master’s level fieldwork student at the Site Name:
the four-month period between DD/MM/YY: and DD/MM/YY:
During this time, I agree to become familiar with the policies and procedures of the Site
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 300 hours. In all of my work, I will observe the established policies and
DD/MM/YYY: . 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
has spent with clients. To the degree that I am able, I will try
of hours Students Name:
to structure Student Name:
time so that he will have a minimum of 15 0 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 Students Name:
. I will complete periodic evaluations of
and, after discussing it with Students Name:
Student's Name: , I will give
him the original to be uploaded to Blackboard.
It is understood that the student has completed all necessary prerequisites for gaining supervised experience
through the counseling internship. The MA in Addiction Counseling program allows students to choose intensive
or online options for the helping techniques, group counseling, and diagnosis and treatment planning courses. We
(student and supervisor) have discussed the student’s choice of course format as part of the internship
arrangement and
agree to proceed with the internship according to the terms described above.
Supervisor Signature Date Student Signature Date
Addiction Counseling
Home Phone:
Work Phone:
procedures of the Site Name:
Supervisor's Name:
, agree to supervise Student's Name:
1 hour of individual supervision per week during the period between DD/MM/YY: and