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Counseling On-Site Supervisor Information and Agreement Form...

NOTE: Site supervisors must hold a master's degree in counseling or a related field and have two year's experience post masters.

On-Site Supervisor's First Name:

On-Site Supervisor's Last Name:

Title:

Email Address:

Site Street Address:

City:   State:   Zip:

Telephone:

On-Site Supervisor's Licensure & Credentials:

Supervisor's Degrees:

Years Counseling Experience:

Concentration or Specialty(ies):

Counseling Student's Name:

Counseling Student's Email Address:

Counseling Student's Concentration:


 On-Site Supervisor Agreement Form

The following are agreement conditions between Winthrop University and  to qualify as an appropriate site placement for , a student in the Counseling and Development Program at Winthrop University.

As the site supervisor, please check the conditions in which you agree to adhere to during the term of your intern's placement:

 I will provide an orientation for the intern regarding the purpose, function, and administrative procedures for our site.

I will provide one hour of weekly supervision.

I will complete a midterm and final evaluation of the intern's performance.

I will allow the student to complete 100 clock hours during the semester, 40 of those being direct contact hours with clients/students for Practicum Level candidates or 300 clock hours during the semester, 120 of those being direct contact hours with clients/students for Internship I and II students.

I will allow the intern to 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 for the intern.)

Because we are deeply committed to the effective training of our students we believe these conditions are paramount for providing the best training possible. If you have any hesitation in providing these learning conditions, please contact the field placement coordinator. If an alternative solution cannot be reached, we may explore the possibility of placing the intern at another site which would better suit their needs.

 As the On-Site Supervisor, by checking this box, I agree to the above conditions while supervising the above named student for the fall/spring semester of this current academic term.

CONTACT INFORMATION
Counseling, Leadership, &
   Educational Studies

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Rock Hill, SC 29733
803/323-2158
803/323-2385 (fax)
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