1
PRACTICUM FIELDWORK CONTRACT
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
Offsite Fieldwork Contract
SITE:
Name:
Address:
Phone Number:
Contact person:
Supervisor Name
Date
Student Name
Site Director Name
Date
Counselor Education and
Supervision Internship
STUDENT:
Name:
Address:
Home Phone:
Work Phone:
I, Student's Name: , agree to provide approximately 100 hours of counseling-related services
as a Doctoral-level fieldwork student at the Site's Name: during the four-
month period between MM/DD/YY: and MM/DD/YY: . 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 within the constraints of
the 100 hours. In all of my work, I will observe the established policies and procedure 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/YY:
and MM/DD/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: has spent with clients. To the degree that I am able, I will try to structure
Student's Name: time so he will have a minimum of 40 hours of face-to-face contact with clients. I
understand that this contact can include co-therapy, in
dividual, group, and/or family therapy done by Student's
Name: . In addition, I will support Student's Name:
in conducting three
Practicum 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 meet with the faculty supervisor periodically. I understand that the faculty member
will provide Student's Name: with group supervisionan average of 1.5 hours per week.
I, , as the site director, of Site's Name: agree to give permission to
Student's Name:
Name:
to release confidential information to Supervisor's
, the off-site supervisor.
Date
I confirm this site is a traditional counseling site as defined in the Practicum/Internship Manual and Handbook.
