FIELD PLACEMENT APPLICATION
College/ Career Counseling Date______
Name of Placement:
Phone Number: FAX Number:
Location:
Number and Street City, St Zip
Additional Location:
Number and Street City, St Zip
Mailing Address:
Number and Street City, St Zip
Trainee Coordinator:
Phone Number: E-Mail:
San Francisco State University, Department of Counseling is committed to equal access for all students. Placement sites must be willing to accommodate students with disabilities, if students can perform the essential functions of the job, and if accommodations requested are reasonable.
Is this agency willing to accommodate students with disabilities? Yes r No r
Is this agency wheelchair accessible? Yes r No r
Description of Services provided & population served:
Counseling Services: Individual - Yes r No r Group - Yes r No r
Family - Yes r No r Workshops - Yes r No r
Age Range of Clients: 0-11 r 12-18 r Adults r Seniors r
Ethnicity of Client Population: Please describe using approximate %.
Type of Supervision**:
Degree (M.A., Ph.D.), Certification (e.g. CRC) held by supervisor/s:
License held by supervisor:
Supervision: r - Individual: 1 Hour/Week Required No. of Hours Provided:
r - Group: No. of Hours Provided:
Methods of Supervision: r Case Presentation r One-Way Mirror r Video Taping
r Audio Recording Required r Process/Progress Notes r Role Play
Audio recordings of trainee interviews with clients are required by this Department. Students are required to play recordings to faculty supervisors. Second year interns are required to have recorded sessions available for faculty supervisor by October 15.
Is recording of interviews allowed by your agency with permission from clients? r Yes r No
Will second-year interns be able to have substantive recorded counseling sessions with clients by October 15? r Yes r No
Responsibilities of Trainee: Please describe the fieldwork experience and responsibilities the trainee will have at your agency. Please attach a copy of description of trainee duties provided to trainees.
Type of Counseling that Trainee will Provide*:
Number of client hours per week the trainees are assigned: (A minimum of 2 and maximum of 8 clients are required for 1st yr. trainees and a minimum of 5 and maximum of 12 clients for 2nd yr. trainees.)
Do you have a didactic training component as a part of your program? r Yes r No
Please describe:
EMPLOYMENT STATUS OF TRAINEE:
r - Volunteer
r - W-2 Employee Rate of Pay $
r - Stipend Amount $
Number of Hours Per Week Required of Trainee:______
Period of Traineeship: From ______To ______
What is your Trainee application process?
Mandatory Time Commitments: (please include as much information as possible, including day, week and time of staff meetings, trainings, etc., if applicable.)
Emergency Protocol for Intern Safety and Client Risk Assessment:
a. Please describe protocol to ensure student safety (please be as specific as possible including instructions given to intern, person in charge when supervisor is unavailable, etc. Attach sheet if helpful):
b. Please describe protocol for client/student risk assessment in your setting and ways in which intern will be supported should that situation arise (please be as specific as possible including instructions given to intern, scope of responsibility, person in charge if supervisor is unavailable, etc. Our expectation is that students will be supported in assessing risk to the degree appropriate to the setting and, at the very least, will receive supervision on triage responsibilities to assess the urgency of referral and referral process appropriate to the situation. Attach additional sheet if helpful):
*Type of counseling provided by intern should be “substantive counseling” content. In other words, interns must be able to engage with students/clients in a way that addresses life issues, family issues, inter and intra personal issues. Counseling should call on intern to use of basic and advanced listening and engagement skills, facilitating client in greater self-understanding within a cultural context as well as help clients define the concern as well as identify pertinent influences, and potential avenues for addressing concerns. Although we understand that some sessions may reflect information giving or transactional interactions, this should reflect only a small portion of the sessions interns engage in as they are not sufficient for developing the counseling skills needed for the internship experience.
** The relationship between the supervisor and intern must be a singular role of that of a clinical supervisor. In the rare occasion where the intern has a pre-existing relationship, the intern must be supervised by someone who has not had a previous relationship (and does not currently have a relationship) with the intern other than that of a clinical supervision relationship, unless a sufficient period of time has passed to render issues of dual relationship inert (2 years based on ACA ethical guidelines). If on the rare occasion a student has received permission from the Department of Counseling to engage in an internship in their worksite or in a student service unit in which the intern has, or continues to, receive services, there must be a clear separation of roles of the supervisor and intern vs. service provider and consumer or administrative supervisor and employee.
The program is committed to a culture that is inclusive of, but not limited to, ethnicity, race, gender, sexual identity sexual orientation, religion, socioeconomic status, national origin, disability, age, and indigenous status. Therefore, we encourage supervisors from all cultural backgrounds to work with our diverse students.
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Attach extra pages with additional information or comments
Field Placement Application: