Counseling, Leadership, and Educational Studies

Field Experience Application

*Type of Application:

Degree Program:

*Field Experience Setting:

Please Note: Applicants must not begin collecting hours until both the candidate and on-site supervisor applications are approved by Counseling and Development.

*First Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip:

*Home Phone:

*Office Phone:

*Email:

*Beginning of Term:

*Ending Term:

Site Information

*Name of Site:

*Site Address:

City:

State:

*Zip:

*Site Phone:

Agreement Form

*The following are agreement conditions between

*, a student in the Counseling and Development Program at Winthrop University and

, to insure professional and ethical behavior by the student while interning at your school/agency.

As the student intern, I agree to adhere to all conditions listed below during the term of my field placement:

I will comply with the rules and regulations of the site and will adhere to all agreements regarding schedules and duties to be completed
I will work a minimum of 100 clock hours at the Practicum Level and 300 clock hours at the Internship Levels during the semester
I will provide a midterm and final evaluation for you to complete regarding my performance
I will follow the ethical guidelines of the national organization in which I belong as well as the sites guidelines
I will remain professional in my role as counselor and bring forth any concern I have to my supervisor immediately
I will use video taping of individual and group counseling sessions for a minimum of three times during the academic semester. (This provision is crucial to our on campus supervision requirements. The inability to meet this condition will result in an incomplete grade.)

If you have any hesitation providing these conditions you must contact the field placement coordinator. Failure to adhere to these standards may result in remediation efforts or withdrawal from the site and the practicum course.

As the student, by checking this box, I agree to the above conditions while interning at the above named site for the fall/spring semester of this current academic term.

Yes