Form

Mailing Address:

Contact Name
First Name Last Name
Contact Phone:
- Area Code Phone Number
Please answer the following questions about the agency:
Are evening hours available for practicum students?

Yes No
Are weekend hours available for practicum students?

Yes No
Length of time agency has been in service:
Please choose the best description of primary population served:
Please choose the best description of primary service provided:
Please provide a brief description of agency services and population served:
Indicate any special skills perferred of a practicum student:
Please answer the following questions pertaining to departmental requirements:
Is taping of client sessions permitted for purposes of supervision (with client permission)?

Yes No
Will the student be able to tape three (3) client sessions for GSU supervision each week?

Yes No
Will the student be able to lead/co-lead a weekly group?

Yes No
Will the supervisor have a masters degree in counseling or a related field with appropriate certification/licenses and have a minimum of two (2) years pertinent professional experience?

Yes No
Will the student be covered by the agency's insurance policy?

Yes No
Are you currently employed at this site?

Yes No
Please supply any other comments regarding this agency's application:
Do Not Complete Fields Below - For Department Use Only!
Approved:
Date Approved
Should be Empty: