Grand Canyon University Masters in Marriage and Family Therapy Practicum Manual

Transcription

1 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Grand Canyon University Masters in Marriage and Family Therapy Practicum Manual College of Health Sciences Department of Professional Counseling And Addiction Studies M.S. in Marriage and Family Therapy Program MFT 615: Pre-Practicum Courses MFT 660: Practicum Courses

2 Table of Contents Part I: Introduction... 3 Planning ahead for the Practicum Experience... 3 Time Commitments to the Practicum Experience... 3 Using a current place of employment to complete the practicum experience... 3 Practicum Fees... 3 Professional Associations and Liability Insurance... 4 State Licensing and Certification Requirements... 4 Overview of Course Objectives and Prerequisites... 4 MFT 615: Pre-Practicum course... 4 MFT 660 A-B: Practicum courses A-B... 5 MFT 660 F-G: Practicum courses F-G... 5 Part II: Roles and Responsibilities... 6 Role and Responsibilities of the GCU, Office of Field Experience Faculty Intern Supervisor. 6 Responsibilities of the Agency... 6 Role and Responsibilities of the Field Experience Supervisor... 6 Responsibilities and Expectations of the Student... 7 Students responsibilities related to the program of study at GCU:... 7 Students responsibilities related to the hosting agency and field supervisor:... 7 Part III: Step by Step Directions for Gaining Approval to Begin the Practicum Experience weeks prior to beginning the pre-practicum course and experience:... 8 At least 8 weeks prior to beginning the pre-practicum course and experience:... 9 At least 6 weeks prior to beginning the pre-practicum course and experience: At least 4 weeks prior to beginning the pre-practicum course and experience: weeks prior to beginning the pre-practicum course and experience: Part IV: Practicum Experience Forms Pre-Practicum/Practicum Document Submission Cover Page Pre-Practicum/Practicum Application Counseling Practicum Site Information Form Acknowledgement of Practicum Guidelines Acknowledgement of California Board of Behavior Science MFT Licensing Requirements. 17 Site Supervisor Information Sheet Weekly Practicum Experience Activities Log Field Supervisor s Evaluation of Practicum Student Student s Evaluation of Field Supervisor

3 Part I: Introduction This manual is designed to provide information about the practicum experiences related to the Master s programs in Counseling at Grand Canyon University. This document provides all the guidelines and forms necessary to meet programmatic requirements. This document also serves as a Memorandum of Understanding between the student, practicum experience site, and the counseling department at Grand Canyon University. A practicum experience is an opportunity to put into practice concepts that GCU students have learned in the classroom and to demonstrate their ability to perform in a professional setting. This learning experience will allow our students to become acquainted with the workplace environments and provide networking opportunities that could lead to employment following completion of the program. During the practicum experience, classroom assignments focused on introspection and identifying personal change, professional growth, and self-assessment will document their professional development. Planning ahead for the Practicum Experience In order to have all the clearances and releases in place to start the pre-practicum course, the student must initiate a formal application for practicum experience with the COHS Office of Field Experience. This must be done at least 16 weeks prior to the date the student plans to begin the pre-practicum course. The student s first step is to contact their academic advisor at GCU to determine the start date of their pre-practicum course. The academic advisor assists students with course scheduling and setting the pre-practicum and practicum start dates. * The student must complete the Pre-Practicum/Practicum Application and fax to the COHS Office of Field Experience. The student must locate and confirm a practicum site. Assistance with acquiring a practicum site is further discussed in Part III Time Commitments to the Practicum Experience Students should plan ahead to meet the commitments of the practicum experience. Most host organizations are often limited to day-time and week-days for providing practicum experiences and if the student does not complete 100 hours of clinical work in the 8 week pre-practicum course, they will not be able to move on to the practicum courses. If the student does not complete a minimum of 150 hours of practicum experience during each of the 8 week practicum courses, they will have to enroll in additional credits of practicum coursework to complete the degree. The practicum student must complete all of their professional time commitment to the host agency even if the student has successfully completed their logged clock hour commitment. Students must discuss and agree upon their practicum experience start and end dates with their site supervisor. It is important for students to confer with the site supervisor on how they will be expected to provide closure to their clients. Remember, to abandon a client is unethical. Using a current place of employment to complete the practicum experience If a student is planning to use their current place of employment to complete a practicum experience they must inform the COHS Office of Field Experience that this is their intention and obtain approval in advance of the start date. Some State Boards may prohibit this practice so students should contact the board in their state to find out if they can complete the practicum experience at their place of employment. If a student already has paid employment with a host agency their hours can only be logged after they have been approved and begun a practicum course. Practicum Fees Generally, the cost of a practicum experience is the cost of the regular university tuition and fees. All university fees will be collected by the university business office. No fees will be paid to the host site supervisor or hosting agency. The practicum student is responsible for their own transportation and fees pertaining to student professional liability insurance, professional memberships, and any background fingerprint checks which may be required by the host site. Additional fees may be incurred by the student if a site requires vaccinations, chest x-rays or other medical clearances. 3

4 Professional Associations and Liability Insurance All practicum students must meet the following prerequisite requirements BEFORE they may register or enter a practicum experience under the auspices of Grand Canyon University. This coverage is not facilitated by GCU directly. The students have to take the initiative, make contacts and take care of these responsibilities themselves. They are: 1. Membership in a Professional Counselor Association. GCU considers affiliation with a professional counselor association as part of its professional expectation for its counseling students. Each counselor-to-be student is to select that professional counselor association that best reflects the particular area focus of counseling into which they are planning to professionally serve. These include the following possible associations: a. American Association of Marriage and Family Therapy ( ) b. American Psychological Association (APA) ( 2. Student professional liability insurance. Each prospective practicum student is required by Grand Canyon University to have their own individual liability insurance coverage prior to the beginning of their practicum experience. Every student must have their own individual insurance even if their host site states that they have insurance that will cover the student. Some professional associations can provide reasonable student rates for insurance. For example, ACA will insure addictions and professional counseling students as part of membership. The minimum coverage specified by GCU for its counseling practicum students is $1,000,000 per claim and $3,000, 000 aggregate. The practicum student must provide the College of Health Sciences Office of Field Experience with copies of their liability insurance and pages specifying coverage limits, dates of coverage and limits of liability. No student will be able to begin a practicum without this coverage. State Licensing and Certification Requirements Students should be aware that State legislatures make periodic changes to licensing rules, including the number of pre-practicum and practicum hours required. It is recommended that they routinely check their state licensing board website to keep up with any changes that may affect their ability to obtain licensure/certification. Failure to do so could affect the student s application for licensure or certification. It may be in the students best interest to obtain any additional hours required by their state prior to graduation. The California Board of Behavioral Sciences requires each intern to register with the Board prior to beginning prepracticum. Below are links that will help you find California State s licensing and certification requirements: California Board of Behavioral Sciences California Board requires that the intern apply for registration immediately following completion of their degree Please review this site and application form carefully as they contain important information and forms regarding MFT licensing requirements. Overview of Course Objectives and Prerequisites MFT 615: Pre-Practicum course Students are required to complete a minimum of 100 hours of clinical work, under close supervision, during the prepracticum experience. A minimum of 40 hours must be direct client contact hours with at least 1 hour under direct supervision for each 5 clock hours worked. 25 hours can be met through completion of coursework within the prepracticum class and the remaining time can be met through provision of support functions to the site. The 25 hours you will receive for coursework should be entered on a separate weekly log and documented in the indirect section in the categories specified for (Other). The practicum will be performed under the supervision of a faculty member and an onsite supervisor approved by the College of Health Sciences Office of Field Experience and the practicum professor. 4

5 Prerequisites for the course are: Completion of all of the courses in Marriage and Family Therapy Program of Study including the following courses: o MFT 511 Introduction to Chemical Dependency Counseling o MFT 505 California Law and Professional Marriage and Family Ethics o MFT 520 Group Counseling Theory and Practice o MFT 500 Counseling Theories o MFT 610 Diagnostics, Assessment and Treatment GPA of 3.0 or better Approval of all application requirements by the College of Health Sciences, Office of Field Experience o Required documents include: Pre-Practicum/ Practicum Application Liability Insurance (Face Sheet) Evidence of Membership to A Professional Counseling Organization Site Information Form Site Supervisor Information Sheet MFT 660 A-B: Practicum courses A-B These supervised practicum courses provide 150 contact hours of opportunity for students to develop their counseling skills and to perform all the activities that a regularly employed professional counselor would be expected to perform, in a supervised setting. At the end of practicum B the student will have acquired a minimum of 300 hours with 100 hours of direct face to face contact. The practicum will be performed under the supervision of a faculty member and an onsite supervisor approved by the college or university. This is a pass/fail course with the minimum passing score of 76% to receive credit. Prerequisites for the course are: Completion of MFT 615: Pre-practicum with a C or higher GPA of 3.0 or better Maintenance of student professional liability insurance in the amount of 1 million, 3 million. Maintenance of an approved site supervisor. o If the site supervisor has been approved in MFT 615, the student may continue with this supervisor. o If a change in supervision and/or site is needed, the student must provide updated documents to the COHS Office of Field Experience before the student is allowed to proceed with changes. Failure to submit these documents in a timely manner will cease the practicum process and delay graduation. MFT 660 F-G: Practicum courses F-G These supervised practicum courses provide an opportunity to gain contact hours that might be necessary to complete any additional state licensure or unmet program requirements related to development of their counseling skills and performance of the activities that a regularly employed professional counselor would be expected to perform in a supervised setting. The practicum will be performed under the supervision of a faculty member and an onsite supervisor approved by the college or university. This is a pass/fail course with the minimum passing score of 76% to receive credit. Prerequisites for the course are: Successful completion of MFT 660B GPA of 3.0 or better Maintenance of student professional liability insurance in the amount of 1 million, 3 million Maintenance of an approved site supervisor. o If the site supervisor has been approved in MFT 615 and/or MFT 660, the student may continue with this supervisor. o If a change in supervision and/or site is needed, the student must provide updated documents to the COHS Office of Field Experience before the student is allowed to proceed with changes. Failure to submit these documents in a timely manner will cease the practicum process and delay graduation. 5

6 Part II: Roles and Responsibilities Role and Responsibilities of the COHS Office of Field Experience and The Faculty Intern Supervisor Responsibilities of the COHS Office of Field Experience The COHS Office of Field Experience will determine if you have met all of the application requirements necessary to begin the practicum experience and will verify completion of all requirements necessary for graduation. Additional responsibilities of The Faculty Intern Supervisor are as follows: Insure that students pursuing the practicum experience understand the nature of the program and the expectations involved. Provide orientation information to the site supervisor. Assist students in the practicum application process if required. Be available to counsel with the student as situations might dictate. Communicate with the practicum student s site supervisor during each practicum section as required by the State Board. Review and sign all final activity logs in order to release for graduation. Communicate with the practicum classroom instructors as necessary. Responsibilities of the Agency Designate a professionally qualified individual to be the site supervisor for the student. Provide the student with guidance and related experiences that meet the required number of client face-to-face clock hours, in group, or in individual settings with clients. Provide the student with an opportunity to learn about the organization s program and management functions to develop organizational insight into the mission and activities of the organization. Provide a meaningful orientation for the student regarding the host organization s purpose, services, organizational structure, and operating practices. Provide for 1 hour of face to face clinical supervision for every 40 clock hours worked. If the supervision takes place in a group setting the number of supervisees will not exceed six members per Provide for student contact with appropriate staff members and clients. Make available space, supplies and other resources needed for carrying out the student s task assignments. Conduct evaluations in accordance with the student s program requirements. Provide a copy to the student and the COHS Office of Field Experience. Ensure the student operates within the appropriate ethical, organizational, professional and legal guidelines for counselors in this kind of counseling setting. Notify the COHS Office of Field Experience immediately in the event the student s performance becomes unsatisfactory. Provide, in writing, special insurance requirements (i.e. liability), contracts to cover the student during the contract period. (Note: The student already has standard counseling liability insurance for student practicum students as a GCU requirement.) The agency retains the privilege of determining treatment modalities. Role and Responsibilities of the Field Experience Supervisor A supervisor has full responsibility for the supervised work of the supervisee, including diagnosis, treatment plan, and prescribed course of treatment. They are also responsible to: Provide instruction and guidance regarding diagnosis and treatment Provide support for professional development Provide feedback to the supervisee that is timely, clear and specific, that is, feedback is delivered soon after an important event and is based on specific performance criteria. 6

7 Ensure a safe work environment Help supervisees explore and clarify thinking, feelings, and clinical strategies that support client treatment. Challenge practice which the supervisor judges to be unethical, unwise, or incompetent Challenge personal or professional blindspots which the supervisor may perceive Bring to the supervisee's attention those personal difficulties of the supervisee that directly affect the supervisee's clinical work and recommend a course of action to address these difficulties. (While the supervisor can recommend that a supervisee seek consultation with relevant professionals, such treatment will not be rendered by the clinical supervisor.) Be available to supervisees at times other than the scheduled supervision slot. Supervisees should obtain phone numbers of their clinical supervisor where they can be reached in case of emergency. The Field Experience Supervisor should also: Orient the student to the work situation and be available on a daily basis for consultation as needed. Participate in the development of the student's plan for the pre-practicum/practicum experience on a course by course basis. Keep records of supervision, including any supervision plan, dates or supervision, notes regarding supervision, including specific clients and cases reviewed. Furnish the student with all the required signatures and documentation necessary to maintain and complete the student's file. Provide 1 hour of face to face clinical supervision for 5 clock hours worked. If clinical supervision takes place in a group setting the number of supervisees should not exceed 8 supervisees. Every two hours of group supervision equals one clock hour of individual supervision. Responsibilities and Expectations of the Student Students responsibilities related to the program of study at GCU: As previously stated the student is to assume sole responsibility for meeting all approval requirements to begin the pre-practicum/practicum experience. The staff of the COHS Office of Field Experience is willing to consult and may be able to assist if necessary with some tasks or issues. These primary responsibilities are not limited to: Thoroughly completing the Step by Step Directions for Gaining Approval to Begin the Practicum Experience located in this document. Complying with all reporting and documentation requirements of the pre-practicum/practicum experience. o Maintain weekly activity logs signed by the site supervisor and submit copies to your Angel classroom instructor each week. o During week 8 of the pre-practicum and practicum courses, each student must fax (or attach to an ) to the COHS Office of Field Experience a completed Supervisor s Evaluation and Student s Evaluation. o Within a week of completion of each Pre-practicum and Practicum course, the student must mail original copies of all corresponding completed, signed and dated activity logs to the COHS Office of Field Experience The COHS Office of Field Experience will review, verify calculation of hours, sign and return a copy of these logs to the student. Students should be sure to keep these records as documentation for their post graduate license/certification submission. Please note you will be required to fill out a California intern log in addition to the one GCU requires. Completing MFT 615 and all MFT 660 course requirements and earning a grade of 3.0 or better in prepracticum and a grade of CR, or credit for practicum sections. Preparing and completing the practicum experience portfolio Students responsibilities related to the hosting agency and field supervisor: As students engage in practicum experiences throughout the country, they serve as ambassadors of Grand Canyon University. Through their interactions and performance, they will be demonstrating to many professionals and members of the general population what Grand Canyon University is all about and the special qualities that our students bring to them. Consequently, practicum students have the responsibility of presenting themselves professionally to the population being served. Our goal is for GCU students to be exemplary role models of the counseling profession. In addition to the requirements related to the practicum experience, GCU also holds the practicum student to some personal and professional standards during the course of the practicum experience. The responsibilities related to the practicum experience include the following Conducting himself/herself in a professional manner at all times. Practicum students must operate according to site guidelines, procedures, and supervision as well as the state and national boards of the profession. If a supervisor gives a directive that appears to be in conflict with the students values or ethics, or creates a 7

8 personal conflict, which cannot be resolved in ordinary communication with the supervisor, the student must immediately contact the COHS Office of Field Experience to set up a telephone conference with the COHS Faculty Intern Supervisor. Carrying out all responsibilities as specified in the practicum experience duties. Arriving on time and work the scheduled times. Dressing appropriately for the agency and/or activity. Discussing with your supervisor the goals and/or skills you would like to attain Being prepared, both for sessions with clients as well as for supervision. Supervisees should attend supervision with an agenda of cases and / or clinical issues that need to be addressed. Be receptive to guidance and instruction from your supervisor, that is, be attentive to feedback and suggestions from your supervisor and follow through on such instructions promptly. It may be necessary to take notes during supervision in order to execute all instructions identified by your supervisor. Inform your supervisor of any difficulties you are having in the areas of delivering services to clients, completing paperwork, or coordinating professionally with other agencies or staff. Always remember: Seek supervision whenever you are uncertain about a situation. If it is an emergency situation and the client is in your office make every attempt to contact your supervisor or other on site licensed clinician before taking action with that client. If your supervisor cannot be reached, contact one of the other site supervisors. You may also consult informally with experienced counselors at your site, but your site supervisor MUST be kept abreast of all emergencies. Counselors must advise their clinical supervisor of all important changes in a case. The results of new assessments must be reviewed with your supervisor at the earliest opportunity to confirm treatment planning. Any changes to the treatment plan must be reviewed with your supervisor BEFORE they are presented to the client. Consult with your supervisor about case closures in advance of closing the case, including the implementation of strategies that may result in a client deciding to terminate treatment. Keep your supervisor informed about clients who are suicidal, homicidal, or threatening harm to others. Notify your supervisor about clients who are involved in child custody disputes, disability determination assessment, or any other matters that affects the client's legal status. Under Federal law you have a duty to warn and a duty to protect. Maintaining client confidentiality is ethically and legally mandated by state and federal regulations. This includes information that any individual is in fact a client at the site as well as any identifying information. Access to client information should only be attempted with the explicit permission of supervisors, and only as needed for facilitation of treatment. Supervisees will not engage in dual relationships with clients, that is, counselors will not Under any circumstances participate in a dual relationship with a client, nor will they provide services to clients they know from other context, such as friends or acquaintances. In the event that someone you know is being seen at the agency, you are expected to remove yourself from situations where the client's treatment and progress are being reviewed. It is your responsibility to alert your supervisor to such situations. A supervisee is responsible for ensuring that all clients are informed of the supervised nature of the work of the supervisee, and of the ultimate professional responsibility of the supervisor. Practicum students must adhere to the code of ethics of Marriage and Family Therapists: The clinical supervisor is legally and ethically responsible, with the student, for the service the student provides and the manner in which the student conducts himself/herself. It is therefore the supervisee's responsibility to keep the supervisor well informed of his or her activities. Openness with and trust in the clinical supervisor will enhance experience of supervision and professional growth. Part III: Step by Step Directions for Gaining Approval to Begin the Practicum Experience Each prospective student is responsible for the timely fulfillment of the following application process. 16 weeks prior (or earlier) to beginning the pre-practicum course and experience: 1. The student must identify one preferred and two alternative sites where they may want to conduct the pre-practicum/practicum experience. Each student is responsible for identifying and arranging the location of their own practicum experience. It is suggested that students identify at least five sites that they 8

9 may be interested in. The students must then consult with the COHS Office of Field Experience to ensure that all of the prerequisite criteria are met and to finalize the site selection arrangements. The practicum sites must be of a nature and type that is approved for practicum hours towards counselor licensure according to state regulations. It is the responsibility of the student to check on this approval status. It should provide appropriate learning opportunities for the application of knowledge (theory, methodology, and research) and skills to practice and the development of professional competence, including appropriate facilities to enhance learning (adequate workspace, access to telephone and computers for site-related work). If necessary, the COHS Office of Field Experience can help the student make contact with any agencies that they are interested in. 2. Prepare and submit a Pre-practicum/Practicum Application to the COHS Office of Field Experience. The first step of the practicum application process is completing the Pre-practicum/Practicum Application Form. Completion of this form will assist in clarifying the student s needs and goals for the practicum experience and will help identify an appropriate practicum experience placement. 3. Confirm eligibility with the COHS Office of Field Experience. 4. Prepare resume and cover letter for site interviews. First impressions are important. Student should prepare a professional resume that they will submit when interviewing with potential sites. There are many tips on preparing a resume on the web, in libraries or in bookstores. Most word processing programs have templates that are very helpful. The resume should be limited to one page if possible. In addition to a resume the student need to develop a cover letter. Make sure this letter is in business letter format. It is important that your resume and cover letter are free of spelling or grammatical errors. 5. Interview with potential Site Supervisor(s). The supervisor to whom students will be assigned must be credentialed at the independent practice level of licensure or certification (listed below), and credentialed to supervise according to state regulations for the discipline. A completed Site Supervisor Information Sheet and a copy of the site supervisor s License must be submitted to the COHS Office of Field Experience prior to final approval of the practicum site. The practicum student will be providing services under the supervisor s license or certification, and they are legally responsible for all that goes on between the student and their clients. The supervisor must be licensed for two years and must hold current state counseling license in at least one of the following areas: Licensed Psychiatrist Licensed Clinical Psychologist Licensed Marriage and Family Therapist Licensed Independent Social Worker Questions that should be asked by the student in the interview include: What is the overall mission of the Host Agency? (A brochure, mission statement, purpose statement would be helpful) What is the brief history of the organization? What is the structure of the organization (i.e. local, national, private, public, non-profit or profitmaking, church related, affiliating organizations, if any, etc.)? What is the planning process of the organization? What is the role of the Marriage and Family Therapist in the organization? How is one s performance reviewed? What are the major problems and difficulties encountered by this organization? What, if any, career development opportunities are available? 6. Sign and submit the Acknowledgement of California Board of Behavior Science MFT Licensing Requirements form to the COHS Office of Field Experience At least 8 weeks prior to beginning the pre-practicum course and experience: 1. Select a Site. Once the student has received confirmation that a potential site has agreed to provide the practicum experience, A Site Information Sheet will be completed and submitted to the COHS Office of Field Experience by the student for approval of the practicum site. 2. Confirm with the COHS Office of Field Experience that the site is approved Generally your pre-practicum will be followed by your practicum at the same host site. If you change sites you must repeat the site approval process described in this manual. 9

10 At least 6 weeks prior to beginning the pre-practicum course and experience: 1. Complete any necessary site requirements such as contracts, vaccinations, fingerprints, chest x-ray that might be required by your site. At least 4 weeks prior to beginning the pre-practicum course and experience: 1. Obtain student professional liability insurance (1 million each claim, 3 million - aggregate) Submit a copy of the face sheet or proof of policy to the COHS Office of Field Experience. 2. Submit a Site Supervisor Information Sheet with a copy of the site supervisor s license to the COHS Office of Field Experience. 3. Submit a completed Acknowledgement of Practicum Guidelines form signed by both the student and site supervisor to the COHS Office of Field Experience 2 weeks prior to beginning the pre-practicum course and experience: 1. Confirm start date, times and practicum plan with site supervisor. Part IV: Practicum Experience Forms Practicum students must use the following forms to complete the pre-practicum/practicum application process and to document their practicum activities. Stand alone versions of each of these documents will be located in your Angel Classrooms as well as the COHS Student Corner. 1. Cover Sheet to be included with all document submissions 2. Pre-practicum/Practicum Application Form 3. Site Information Sheet 4. Site Supervisor Information Sheet 5. Acknowledgement of Practicum Guidelines as stated in the Counseling Practicum Manual. 6. Acknowledgement of California Board of Behavior Science MFT Licensing Requirements 7. Activity Log 8. Supervisor Evaluation form 9. Student Evaluation of Site Supervisor form All completed forms should include a completed cover sheet and be submitted by the method requested: Mail: Grand Canyon University Fax: College of Health Sciences cohsfield@gcu.edu Office of Field Experience Phone 1: Box 478, P.O. Box Phone 2: Ext **If you need help with any portion of the pre-practicum/practicum process appointment times may be scheduled by calling the COHS Office of Field Experience. 10

11 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Pre-Practicum/Practicum Document Submission Cover Page To: Office of Field Experience Liaison College of Health Sciences Grand Canyon University From: Date: # Pages (including cover): Program of Study: MS: Marriage and Family Therapy Practicum Course: (check one) MFT 615 MFT 660A MFT 660B MFT 660F MFT 660G Please check the boxes of the all documents you are submitting: Pre-practicum/Practicum Application Form Insurance Acknowledgement of Practicum Guidelines Site Information Sheet Site Supervisor Information Sheet and copy of License Supervisor Evaluation form Activity Log Student Evaluation of Field Supervisor Other: 11

12 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Pre-Practicum/Practicum Application To be prepared by the student and electronically submitted to the COHS Office of Field Experience at least 16 weeks prior to registration into the pre-practicum course Student Name: Student ID#: Address 1: Address 2: City: State: Zip: Alternate address (other than my.gcu.edu): Phone (H): (W): (Cell): Program of Study: MS: Marriage and Family Therapy Total semester hours completed: Anticipated Start Date of Pre-Practicum: (obtained from academic advisor) Name of preferred host agency: Address 1: Address 2: City: State: Zip: Type of Host Agency: Proposed Field Supervisor Name: Field Supervisor s Position: Field Supervisor s Licenses/Certificates held in counseling: Field Supervisor s Degrees: Field Supervisor s Phone: address of Field/Site Supervisor: Name of alternative site #1: Contact Name: Contact Phone: Name of alternative site #2: Contact Name: Contact Phone: 12

13 What contacts and or arrangements, if any, have you already made with the preferred host agency? (Note: The COHS Office of Field Experience must also establish communication with your host agency and site supervisor prior to acceptance into the practicum experience) Describe any proposed practicum duties or tasks that you have already discussed with your proposed field supervisor (if any). Date Submitted to the COHS Office of Field Experience: 13

14 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Counseling Practicum Site Information Form Student Name: Student ID#: Program of Study: MS: Marriage and Family Therapy Practicum Course: (check one) MFT 615 MFT 660A MFT 660B MFT 660F MFT 660G Site Name: Address 1: Address 2: City: State: Zip: Type of Host Agency: Hours of Operation: Site Phone Number Site Supervisor s Name: Site Supervisor s Position: address of Site Supervisor: Phone number of Site: Licensure and approval (by state site, e.g., AZ OBHL, CARF, JCAHO) List all: Description of treatment population at site: 14

15 Description of treatment modalities and approaches employed at site: The practicum site must be of a nature and type that is approved for practicum hours towards counselor licensure according to state regulations. It is the responsibility of the student to check on the practicum site s approval status. State your findings related to site s approval status (if possible, attach a copy of approval status documentation). Describe how the practicum site provides appropriate learning opportunities for the application of knowledge (theory, methodology, research), skills to practice, and the development of professional competence, including appropriate facilities to enhance learning (adequate workspace, access to telephone and computers for site-related work): 15

16 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Acknowledgement of Practicum Guidelines as Described in this Counseling Practicum Manual I, have read the guidelines for pre-practicum and practicum as stated in the Marriage and Family Counseling Practicum Manual and I agree to abide by them. Maintaining client confidentiality is ethically and legally mandated by state and federal regulations. Compliance to HIPAA regulations is required. This includes information that any individual is in fact a client at the site as well as any identifying information. Gossiping within the site or outside the site about client issues is not allowed. Practicum students may be recommended for university disciplinary action and dismissed from the program if it is determined that they have violated professional ethics and or acted in a way that is detrimental to the welfare of the clients. I also understand that State legislatures make periodic changes to licensing requirements and I am therefore responsible for understanding the changes that may affect my ability to obtain licensure/certification in my state. Student Signature: Date: Practicum Field Supervisor: I, have read and understand the guidelines for pre-practicum and practicum as stated in the Counseling Practicum Manual. Supervisor Signature: Date: 16

17 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Acknowledgement of California Board of Behavior Science MFT Licensing Requirements I, certify that I have read the rules and regulations as stated on the California Board of Behavioral Health website regarding MFT licensing requirements ( and have reviewed the application required for state licensure. ( Student Signature: Date: 17

18 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Site Supervisor Information Sheet Student Name: Student ID#: Program of Study: MS: Marriage and Family Therapy Site Name: Address 1: Address 2: City: State: Zip: Site Supervisor s Name: Site Supervisor s Title: Site Supervisor s Phone Number: address of Site Supervisor: Site Supervisor s License and/or Certification number: Expires: State Board or Dept. Number of years experience as a licensed/certified counselor: Have you supervised master s level counseling students in the past? YES NO If so, for how many semesters? Education Institution and division/school: Major Highest degree earned Year of graduation Please attach a copy of the most recent license/certification. Site Supervisor s Signature: Date: 18

19 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Weekly Practicum Experience Activities Log Must be completed and signed by both the student and the site supervisor weekly. Hours must be calculated using.5 for 30 minutes and.25 for 15 minutes. Miscalculated logs will cause a delay in processing and/or diploma. Student Name: Student ID#: Practicum Course: (check one) Week # MFT 615 MFT 660A MFT 660B Start Date: MFT 660F MFT 660G End Date: Site Name: Site Supervisor s Name: Direct Contact Hours Mon Tue Wed Thu Fri Sat Sun Total Assessments Individual Counseling Family Counseling Couples Counseling Group Counseling Client Education Crisis Intervention Other: (Specify): Total Direct Client Contact Hours for the Week: Indirect Contact Hours Mon Tue Wed Thu Fri Sat Sun Total Individual Supervision Group Supervision Staff Meetings In-Service Trainings Conferences (Only if directly related) Preparation and Study (<5hrs/week) Treatment Planning and Development Progress Notes Case Report Writing Other: (Specify) Total Indirect Client Contact Hours for the Week: Required Signatures: Student (signature required each week) Date Site Supervisor (signature required each week) COHS Faculty Intern Supervisor (Signature required following completion of course) Date Date 19

20 Grand Canyon University College of Health Sciences, Office of Field Experience Box 478, P.O. Box Fax: Field Supervisor s Evaluation of Practicum Student This form must be completed by the Practicum Supervisor and mailed to the COHS Office of Field Experience within one week of completion of each practicum course. Student Name: Practicum Course: (check one) MFT 615 MFT 660A MFT 660B MFT 660F MFT 660G Site Name: Site Supervisor s Name: Evaluation Start Date: Evaluation End Date: Evaluation Metrics and Scale Not Observed Poor Below Average Average Above Average Superior Understanding of counseling process Understanding of client dynamics Understanding of diagnosis/assessment Understanding of treatment planning process Understanding of professional ethics Maintains appropriate boundaries Understanding of site system Openness to feedback Respectful Self-motivated Emotional maturity Listening skills Group counseling skills Verbal skills Written skills Overall counseling skills Comments: Required Signatures: Student Date Site Supervisor Date 20