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Clinical Forms

Required Paperwork to begin Practicum / Internship experience (April1 deadline for starting Practicum in the Fall semester and December 1 deadline for starting Practicum in Spring semester)

Clinical Site Approval Request Form – Clinical Mental Health Counseling

Clinical Site Approval Request Form – Community Counseling

Clinical Site Approval Request Form – Marriage, Couple, & Family Counseling & Therapy

Clinical Site Approval Request Form – School Counseling

Clinical Site Approval Request Form – Student Assistance Coordination in the Schools

Clinical Site Agreement Form – Educational Specialist Degree in Marriage and Family Therapy

On-Site Supervision Agreement

Site Supervisor Vita

STEP Office Counselor Education Field Placement Form

“Practicum Paperwork Requirements” Form

 

Consent for Video- / Audio-taping

Permission to Audio-Videotape Consent Form for Use in Individual Supervision

Permission to Audio-Videotape Consent Form for Use in Individual and Clinical Team Supervision

 

Practicum and Internship Activity Logs

Practicum Activity Log: PDF

Internship Activity Log: PDF

Practicum Activity Log: Excel version

Internship Activity Log: Excel version

Practicum Activity Log for MCFCT students: PDF

Internship Activity Log for MCFCT students: PDF

Practicum Activity Log for MCFCT students: Excel version

Internship Activity Log for MCFCT students: Excel version

 

Supervision Form and Evaluations

Practicum Evaluations

Practicum Evaluation of Counselor – On Campus Individual Supervisor

Practicum Evaluation of Counselor – Site Supervisor

 

End of Semester Internship Evaluations

Supervisor’s Evaluation of Counselor-Clinical Mental Health Counseling

Supervisor’s Evaluation of Counselor-Community Counseling

Supervisor’s Evaluation of Counselor-Marriage, Couple & Family Counseling & Therapy

Supervisor’s Evaluation of Counselor-School Counseling

 

Weekly Supervision Session Log (for On Campus and On Site Supervision) - with Cover page/Directions

Weekly Supervision Session Log (for On Campus and On Site Supervision) – without Cover page (to make copies for additional weeks of supervision session logs)

 

Student Evaluation of Supervisor

 

Guidelines for K-12 Comparative Analysis or Agency-Organizational Analysis

K-12 Comparative Analysis

Agency-Organizational Analysis

 

Internship Conclusion Evaluations

Student Evaluation of Clinical Site

Evaluation of Clinical Program by Site Supervisor

 

Requirement of Professional Liability Insurance

Students who plan on starting Practicum in the Spring 2011 or afterwards are required to obtain their own professional liability insurance in addition to the coverage provided through the College and/or his/her placement.  A copy of the student’s certificate of insurance needs to be submitted to his/her Practicum or Internship course instructor at the beginning of the semester and when the student renews his/her professional liability insurance.  While the Department requires students to purchase professional liability insurance to adhere to the best practice, it should be noted that it is a rare occurrence that would require the protection provided by professional liability insurance.

The Department suggests membership in American Counseling Association (ACA) and enrollment in the professional liability insurance plan that is available to all ACA graduate student members.  For the students in School Counseling Program, American School Counselor Association (ASCA, a division of ACA) also offers the professional liability insurance plan. Similarly, the students in Marriage, Couple and Family Counseling and Therapy Program may obtain a professional liability insurance through membership in American Association for Marriage and Family Therapy (AAMFT).  Each student will need to evaluate the clinical site to determine which professional liability insurance is appropriate.  Student membership benefits for ACA, ASCA, or AAMFT can be found in its respective website, counseling.org, schoolcounselor.org, or aamft.org.

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