ࡱ> Z\YS bjbj 42vtivtiDDDDDXXXX<4X"h( |"~"~"~"~"~"~"$e%(j"D"DD"/// DD|"/|"//VX!@"#! h""0"!x((""(D0"8/"""(X : ɫֱ Counseling Education Program Practicum/Internship Site Supervision Agreement A. Student Information Name:________________________________________________ Phone:________________ Address:_______________________________________________________________ E-mail:_________________________________________________________________ B. Site Information Name:_________________________________________ Phone:__________________ Address:________________________________________________________________ Populations served:_______________________________________________________ C. Length of agreement Practicum/Internship Duration: Beginning date __________ Ending date ____________ Hours per week: _________ Days of Week: __________________________ _______ (student initials) I have verified with my site supervisor that I am agreeing to complete my internship in the timeframe provided. ( A copy of site supervisors resume or vita must be attached to site agreement.( D. Supervisor Information Name:_________________________________________ Title:_______________________ E-mail:________________________________________ Phone:______________________ Licensure/Certifications Attained: ( Licensed Professional School Counselor ( LPC ( LMFT ( NCSC ( LCSW ( LSATP ( Licensed Psychologist ( RN ( LCAS ( CSW ( CSAC ( Licensed Psychiatrist ( Other___________________________________(year attained______) State where licensure/certification is granted _____________________ Degrees Held (Master's in Counseling or related field required; Doctorate preferred) (Please list degrees and conferring university) ________________________________________________________________________ ________________________________________________________________________ Employment history (please give last 2 employers) ________________________________________________________________________ ________________________________________________________________________ Experience providing counselor supervision and/or training for providing supervision ________________________________________________________________________ ________________________________________________________________________ E. Practicum Recording Requirements Students are required to record (video recording is preferred) some of their sessions with the client's permission obtained through a signed consent form. Students are required to submit a minimum of one recording per week for review with their university supervisor. F. Responsibilities of Supervisor and Practicum Student Faculty Supervisor Responsibilities: Meet with students a minimum of one and a half (1.5) hours per week for university supervision Review NSU Practicum and Internship Handbook with students Assist the student with the planning of the practicum experience Conduct a minimum of two (2) site visits per semester to observe students and/or meet with site supervisor. Evaluate the student Site Supervisor Responsibilities: Provide a minimum of one (1) hour of weekly individual or group supervision Review Practicum Handbook; understand student requirements & responsibilities. Assist the student with the planning of the practicum experience Meet with University Supervisor at least once per semester. Maintain contact with the student's university supervisor to communicate the students progress and to express any concerns that may arise Evaluate the student Practicum student's responsibilities: Adhere to the policies and procedures of the site Represent themselves and the university in a professional manner Follow the American Counseling Associations and/or American School Counselor Associations Ethical Guidelines Complete self-evaluations for counseling skills and review of recorded sessions. Evaluate the university & site supervisors (mid & end of each semester) G. 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