Draw up a typed contract that explicitly describes the agreement between you the student, the supervisor, and 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
Onsite Fieldwork Contract
STUDENT:
Name:
Address:
Home Phone:
Work Phone:
AGENCY:
Name:
Address:
Phone Number:
Contact person:
hours of counseling-related
during the
. During this time,
. 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
hours. In all of my work, I will observe the established policies and procedures of the Site's
.
I, Supervisor's Name:
, agree to supervise Student's Name: approximately
1 hour of individual supervision per week during the period between DD/MM/YY:
and DD/MM/YY: . 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:
will try to structure Student's Name:
has spent with clients. To the degree that I am able, time
so that he will have a minimum of 150 hours of
face-to-
face contact with clients. I understand that this contact can include co-therapy, individual, group, and/or family
. In addition, I will support Student's Name:therapy done by Student's Name: in
conducting two (Internship) taped sessions or provide & document live supervision. I will complete periodic
evaluations of Student's Name: and, after discussing it with him, will submit the original into
LiveText. I am aware that I will communicate with the faculty supervisor periodically. I understand that the
faculty member will provide John with group supervision an average of 1.5 hours per week.
I confirm
this site is a traditional counseling site as defined in the Practicum/Internship Manual and
Handbook.
Supervisor Name Date
Student Name
Date
INTERNSHIP FIELDWORK CONTRACT
Counselor Education and Supervision, PhD Internship
I, Student's Name: agree to provide approximately 200
services as a Doctoral-level fieldwork student at the Site's Name:
four-month period between DD/MM/YY: and DD/MM/YY:
I agree to become familiar with the policies and procedures of the Site's Name:
the
200
Name:
