INTERNSHIP AGREEMENT Page 1
*Please type or print all information except signatures.
Student Name: / Student ID:Address:
City: / Province: / Postal Code:
Phone: / E-Mail:
Practicum Course: / CPC 651 / CPC 652 / CPC 653 / CPC 633
Quarter/Year: / Winter/20 / Spring/20 / Summer/20 / Fall/ 20
SUPERVISOR & INTERNSHIP SITE INFORMATION
Supervisor’s Name: / Supervisor’s Phone:Supervisor’s E-mail:
Highest Degree Received: / Certification/License#:
Name of Professional Association:
Years Post-Certification/Licensure Clinical Experience:
Years of Supervisory Experience:
Agency/Private Practice Name:
Agency/Private Practice Address:
City: / Province: / Postal Code:
Agency /Private Practice Phone:
INTERNSHIP AGREEMENT TERMS
The Internship Coordinator of City University of Seattle must approve this contract before students make any arrangement or agreement with the Internship Supervisor.
It is agreed between City University of Seattle and (Supervisor’s Name)
of (Agency/Private Practice Name)
that the above-named agency will provide an internship. This internship will include a new learning experience, supervised client contact, introduction to agency policies, and interaction with staff members. The student and supervisor will design an internship including schedule, supervision format and frequency, required staff meetings, and client contact arrangements.
The supervisor agrees to provide those professional services necessary to properly facilitate the City University intern’s learning according to the requirements of the Counselling Program. The University agrees to provide the supervisor with appropriate materials related to the requirements and expectations of the Counselling Program and consultation as needed.
Supervisor’s Signature / Date / Intern’s Signature / Date
CityU Internship Coordinator’s Signature / Date
CPC 651/652/653 (Practicum I/II/III)
INTERNSHIP AGREEMENT Page 2
*Please type or print all information except signatures.
Please write a descriptive paragraph on each of the questions below.
Please give a demographic description of the clients with whom the intern will work.[i.e. age (children, teenagers, elders); ability (developmentally delayed, gifted); families, pregnant teenagers, a wide variety of clients].
What general responsibilities will the intern have, and what types of interventions will the intern use with clients? (i.e. behavior modification, family systems interventions, group therapy).
What is the time schedule of the internship (days of the week and hours worked each of those days)?
What is the supervision type (individual, group) and frequency (day of the week and time)?
What type of staff meetings will the intern attend? (i.e. general staff meetings, smaller unit meetings, specific case staffing groups, management meetings, etc.)
Briefly describe the philosophy and approach of the agency/site.
Supervisor’s Signature / Date / Intern’s Signature / Date
CityU Internship Coordinator’s Signature / Date
Internship Agreement Page 1