Interim Practicum/internship/field Experience Contract Form

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Wake Forest University
Department of Counseling
Interim Practicum/Internship/Field Experience Contract
The Interim Contract is required during times in which a Wake Forest University counselor-in-training
intends to engage in on-site experiences outside of the regular semester (e.g., before or after the Practicum
or Internship course) in which they are registered is in session. For example, students who wish to work
on-site during the Wake Forest University winter break in December and January, or students who wish
to work on-site prior to the beginning of classes in August must complete this contract.
This contract needs to be signed, returned to and approved by the Practicum/Internship course instructor
of record prior to beginning work at the site.
Student: _________________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________________
Phone: (Mobile) _________________________________________
(Work) __________________________________________
Email: ______________________________________________________________
Internship Site: ___________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________________
Phone: ____________________________________________ Ext. __________________
Site Supervisor: ___________________________________________________________
Phone Number: ___________________________________________________________
Email: ___________________________________________________________________
This contract covers the period of _____________________ to ____________________.
I, _________________________________ (student name) am/was enrolled in the
Practicum/Internship/Field Experience (circle one)
course during_____________________________(semester/year).
___________________________________________ is the instructor of record.

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