Draw up a typed contract that explicitly
describes the agreement between you the student, the supervisor, and the site,
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
Phone Number:
Contact person:
Supervisor Name
Student Name
Site Director Name
Counselor Education and
Supervision Internship
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:
to release confidential information to Supervisor's
, the off-site supervisor.
I confirm this site is a traditional counseling site as defined in the Practicum/Internship Manual and Handbook.