Interim Practicum/internship/field Experience Contract Form (Page 2 of 2) in pdf

A. The Site Supervisor will be the primary contact person during the time specified

above and will:

1. Provide a minimum of one hour per week of clinical supervision conducted by

the site supervisor. (Our department’s national accreditation requires that

supervision be formally arranged. Students are strongly encouraged to record

counseling contacts for purposes of supervision by site supervisor.)

2. Provide appropriate space for the counselor-in-training, as well as the

opportunity to record clients.

3. Be available to the counselor-in-training in case of emergency at the site

4. Understands that the University Supervisor is not readily available during the

interim period because it falls outside of the standard course time and/or

semester.

5. Work with the counselor-in-training to assure that course requirements and

activities specified in the contract will be completed.

6. Evaluate the intern’s performance at the mid-term and end of the semester.

B. The Counselor-in-Training will:

1. Maintain a schedule, agreeing to formally notify the site supervisor for

approval if a change is necessitated. It is understood that the schedule will

conform to the work calendar of the site.

2. Carry out the specified activities and responsibilities that meet the internship

requirements as related to the specific site.

3. Keep a log that records time spent at the site during the interim, and including

weekly descriptions of activities. Logs will be reviewed and signed by the site

supervisor during the weekly supervision session.

Because the university is not officially in session during the interim period, it may be difficult for

the intern or site supervisor to contact the instructor of record or other faculty members.

However, should any concerns or questions arise; the intern and/or site supervisor is encouraged

to contact the instructor or another faculty member. The main office number is (336) 758-2317.

This agreement is accepted by the three parties with the expectation that its conditions will be

met. In the event that those expectations are not met, the concerned party agrees to initiate

communication to identify and discuss the difficulty, and to explore how barriers can be

removed.

Student: ____________________________________________ Date: ____________

Site Supervisor: ______________________________________ Date: ____________

Course Instructor: ___________________________________ Date: ____________

Interim Practicum/internship/field Experience Contract Form Page 2