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1 Internship Site and Supervisor Registration Department of Counselor Education Adams State University Directions 1. Fill out this form prior to beginning your Internship experience and by deadline. It is preferred that you fill out this form along with your site supervisor. If you cannot do so, please fill out part A and then provide your supervisor with the rest of the form. Your supervisor will then return the form to you so you can to the Clinical Coordinator. 2. Save the form as your last name, first name, and name of form, e.g. DoeJaneInternshipSiteandSupervisorRegistration 3. Attach the form to an and to the Clinical Coordinator at First time application? * *If this is your second application, please state why (e.g. switched to a new supervisor, adding a second site etc.) A. Student Information Name Cohort Student ID # Semester/ Year Student Liability Insurance Expiration Date* *Students are responsible for renewing their liability insurance annually and sending in the insurance renewal to the Clinical Coordinator.

2 Pre-requisite Information By the time you begin Internship, have you or will you have completed the following required courses for Internship? You cannot enroll in Internship if you haven t completed the required courses below. COUN 537, Practicum COUN 540, Introduction to Professional School Counseling (SC) COUN 555, Clinical Mental Health Counseling (CMHC & AC) COUN 549, Foundations of Addictions (AC) COUN 560, Special Issues in Addiction Counseling (AC) FYI: You cannot enroll in Internship II if you have not completed or are not enrolled in the following required courses during the Internship II semester: COUN 541, School Counseling Paradigms and Practices, COUN 542, Diagnosis and Psychopathology, & COUN 561 Assessment, Diagnosis, and Treatment of Addictions. B. Site Information Name of Site Site Setting (select one) Clinical Mental Health Counseling School Counseling Addiction Counseling Types of services provided to clients/ students at site Website* *If there is no website, please write up a general description of site Tentative job duties for Internship student

3 Is the student currently employed at this site? * *If yes, please describe the new, additional duties the employee will be assuming for their Internship experience. C. Supervisor Information Supervisor Name Address Phone Qualifications (all fields required) a. Highest degree earned (e.g. MA or Ph.D.) b. Degree concentration (e.g. Counseling, Psychology) c. Year degree awarded (e.g. 2000) d. Professional counseling licenses and/ or certifications and numbers (e.g. LPC #1234) e. Number of years as a counselor post master s degree (2 years minimum) f. Have you received training in counseling supervision (e.g. a minimum of three clock hours in counseling supervision that includes an understanding of models and theories of counseling supervision, ethical issues relevant to counseling supervision, and multicultural issues relevant to counseling supervision? * If yes, please provide a summary of your training and qualifications in counseling supervision. *If no, please note you will be required to participate in a website-based training on counseling supervision, provided free of charge by Adams State University.

4 g. Have you ever received a disciplinary action from your state regulatory agency and/ or department of education? * *If yes, please provide a summary of the disciplinary action. D. Contract, Schedule & Agreement Statements 1. Internship Contract (The purpose of this agreement is to provide a qualified graduate student with an Internship experience in the field of counseling) The University Agrees: to assign a Faculty Instructor to facilitate communication between the University and the Site; to provide students who are not receiving payment of any form with coverage under the Colorado Workers Compensation Act [more information can be provided on section , sub-section (7)(a), and (b)]; to notify the student that he or she must adhere to the administrative policies, rules, standards, schedules, and practices of the Site; that the Faculty Instructor shall be available for consultation with both Site Supervisor and student and shall be immediately contacted should any problem or change in relation to the student, Site, or University occur; and that the Faculty Instructor is responsible for the assignment of the Internship grade. The Internship Site Agrees: to assign a Site Supervisor who has the appropriate credentials, time and interest for training the student; to provide opportunities for the student to engage in a variety of counseling activities under supervision and for evaluating the student s performance; to provide the student with adequate work space, telephone, office supplies, and staff to conduct professional activities; to provide the opportunity for audio/video recordings for use in supervision or to provide live supervision of the student s interactions with clients/ students; and to participate in a site visit (or phone call) with the Internship I and/or Internship II instructor (or designee) to discuss the student s areas of growth; this visit is initiated by the instructor.

5 The Internship Student Agrees: 1. to read and understand the ACA Code of Ethics and/ or ASCA s Ethical Standards for School Counselors and practice in accordance to these standards; to keep Faculty Instructor and Site Supervisor informed regarding internship experiences; to demonstrate a minimal level of competency in specified counseling knowledge, skills and attitudes in order to receive a passing grade; to attend classes and supervisory sessions fully prepared as outlined by the course requirements and supervisors expectations; to develop a work schedule with Site Supervisor that will be most conducive to student learning; to complete documentation as required by Site and University; to maintain student liability insurance coverage throughout internship; and to comply with any other requests of the Site, such as completing HIPAA training, background checks, or drug testing Student Agreement Statement: I understand and agree to perform the responsibilities listed in the contract. I understand and agree to practice my counseling in accordance with the ACA Code of Ethics/ ASCA Ethical Standards for School Counselors. I understand that it is my responsibility to keep my Faculty Instructor & Site Supervisor informed of my on-site activities and provide them with the appropriate material needed for supervision. Student Name (as signature) Date 3. Anticipated Weekly Schedule te: The hours need to spread out over the entire academic semester. If the student remains at the same site for Internship I and II, hours should be spread out over both semesters. Mon. Hours Tues. Wed. Thurs. Friday Sat. Sun.

6 4. Supervisor Agreement Statement I agree to meet weekly with my supervisee as stipulated by Adams State University s course requirements. I can find out more information about these requirements via the Department of Counselor Education website. Supervisor Name (as signature)* Date Clinical Coordinator Name (as signature) Date *By signing this form, your name will be automatically added to our site database. Please mail the Clinical Coordinator at if you wish to have your name removed from this database.

Name. Cohort. Student ID # Course Semester/ Year. Student Liability Insurance Expiration Date*

Name. Cohort. Student ID # Course Semester/ Year. Student Liability Insurance Expiration Date* Practicum Registration Department of Counselor Education Adams State University Complete this form with your prospective Site Supervisor. Save the form as your last name and name of course, e.g. Doe_Practicum.

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