PRACTICUM FIELDWORK CONTRACT
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
Student:
Address:
Home Phone:
Work Phone:
AGENCY
Name:
Address:
Phone Number:
Contact person:
I, Student's Name: agree to provide approximately hours of counseling-related
services as a Doctoral-level fieldwork student at
the Site's Name:
and MM/DD/YY:during the four-month period between 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 with any other therapy-related or educationally relevant
experiences that would be helpful within the constraints of the hours. In all of my work, I
will observe the established policies and procedures of the Site's Name:
.
, agree to supervise Student's Name:
approximately 1 hour of individual supervision per week during the period
I, Supervisor's Name: a
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:
h as spent with clients. To the degree that I am able, I will try to structure Student's Name: t
t
time so that he will have a minimum of 40 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:
.
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 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
Counselor Education and Supervision Practicum
100
100
