EXTERNSHIP SITE INFORMATION (For ACCESS Data Base)
NAME OF PLACEMENT
SUPERVISOR (S)NAME, ADDRESS, PHONE AND FAX OF CONTACT PERSON AT SITE
LOCATION
(city or suburbs, accessible by EL or other public transportation?)TYPE OF SETTING
(use codes)
THEORETICAL ORIENTATION
(see codes)
CLIENTS SERVED BY AGENCY
(use codes)SERVICES PROVIDED BY AGENCY
(use codes)CLIENTS SERVED BY STUDENT
(use codes)SERVICES PROVIDED BY STUDENT
(use codes)DURATION OF PLACEMENT
# HOURS / WEEKREQUIRED DAYS AND TIMES
(if known)APPLICATION REQUIREMENTS
APPROXIMATE DUE DATE*
PAST STUDENTS WHO HAVE DONE THIS PLACEMENT
* Approximate due date is based on available information or on past due dates for this site (it is subject to change, and you should verify the date if confirmation of the date is not included in this packet).
CODES
Practicum / Internship Setting Codes
1. Community Mental Health Center
2. Health Maintenance Organization
3. Medical Center
4. Military Medical Center
5. Private General Hospital
6. General Hospital
7. Veterans Affairs Medical Center
8. Private Psychiatric Hospital
9. State / County Hospital
10. Correctional Facility
11. School District / System
12. University Counseling Center
13. Medical School
14. Consortium
33. Other (e.g., consulting), please specify
Activity Codes (Services Provided by Agency or Student)
1. Administration
2. Assessment
a. Intake/Diagnosis
b. Neuropsych Assessment
c. Personality Assessment
d. Intelligence Testing
e. Educational Assessment
3. Consultation
4. Psychotherapy
a. Individual
b. Group
c. Short-term
d. Long-term
5. Research
6. Supervision
7. Teaching
33. Other (e.g., community-based intervention), please specify
Types of Clients Served
1. Infants / Toddlers (0-2)
2. Pre-school children (3-5)
3. School-aged children (6-12)
4. Adolescents (13-17)
5. Adults (18-64)
6. Older Adults (65+)
7. Couples
8. Families
9. Gay, Lesbian, Bisexual, Transsexual
10. Disabled (Physical, Visual, Deaf, Developmental)
11. Inpatient
12. Outpatient
13. Chronically Mentally Ill
Theoretical Orientation
1. Psychodynamic
2. CBT
3. Cognitive
4. Behavioral
5. Eclectic
6. Family Systems
7. Interpersonal
8. Other, please specify