SCHOOL PSYCHOLOGY FIELD TRAINING APPLICATION Harold Abel School of Psychology Capella University

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1 Form L SCHOOL PSYCHOLOGY FIELD TRAINING APPLICATION Harold Abel School of Psychology Capella University Directions: Complete this application, as well as all other requested documentation, and submit to the Field Training Department. Deadline: All documents must be received no later than 1 quarter in advance of the proposed start date for practicum and 2 quarters in advance of the proposed start date for internship. Written notification from the Director of Training must be received before registering for either practica or internship and prior to beginning the approved field placement. LEARNER INFORMATION Learner Address Date of Application Phone (h) Phone (w) This field training application is for a SCHOOL PSYCHOLOGY (circle one): 350 hour 1200 hour PRACTICUM FULL-TIME INTERNSHIP (1 full school year) START & END DATES: Field Training will begin on,, 20 (Month) (Day) (Year) Field training activities are expected to be completed on,, 20 (Month) (Day) (Year)

2 LEARNER SELF-ASSESSMENT: FIELD TRAINING READINESS STRENGTHS Indicate what academic and personal strengths, proficiencies, experiences, training, and educational advantages you bring to field placement. AREAS FOR GROWTH What areas of your professional education require further attention, development, refinement, or maturity that can be met by proposed field training? OVERALL GOALS OF FIELD TRAINING What personal, academic, or professional goals will be met by field placement?

3 ANTICIPATED FIELD TRAINING SCHEDULE SCHEDULE: Note the days and times you will be on site. Mondays: From to Tuesdays: From to Wednesdays: From to Thursdays: From to Fridays: From to Other: Practicum hours should total hours per week on site Intern hours must total 40 hours per week on site Note: All school psychology practicum and intern trainees must maintain a consistent work schedule. Any permanent deviations from this schedule must be approved by the site supervisor, as well as the psychology field training office at Capella University. ENROLLMENT: Check the quarters you plan to be enrolled for practicum/internship Fall Winter Spring Summer Note: Practicum spans 2 consecutive quarters, internship spans 3 consecutive quarters. Select the quarters you plan to be enrolled for practicum/internship. Learners must be enrolled during the time that they are accruing field training hours on site. TRAINING SITE INFORMATION School District Address Phone Number(s) Website URL Is the district in compliance with all standards, policies, procedures, and protocols mandated by your state license, accrediting body, or professional affiliation? Yes No (If no, attach explanation) Type of school district: Public Public/Independent Private Educational Cooperative Dept. of Defense (DoD) Other (specify)

4 This district is located in primarily which type of geographical area? Urban Suburban Rural SIZE OF DISTRICT For the entire district, please indicate the total number of: Students School Social Workers Paraprofessional Counselors Certified School Psychologists Other Psychologists (e.g., clinical) Educational Diagnosticians High Schools Middle Schools Elementary Schools Field Training Applicant: Have you ever been employed by this district? Yes, currently Yes, in this past No Please check all that apply in regards to your relationship with this potential training site. I know someone in the district and I have contacted them about a possible practicum/internship This district was recommended to me by a professional association A faculty member/mentor at Capella advised me to pursue this training site (Who? ) I am currently employed in this district as a (list your job title) I was previously employed in this district as a (list your job title) I have provided contract services to this district: (specify nature of the services) A district employee recommended that I pursue field training at this site. The district contacted me to inquire about my interest in completing field training at their site I have no previous contacts with this district SCHOOL PSYCHOLOGIST S ROLES/FUNCTIONS AT PROPOSED TRAINING SITE Indicate the average amount of time school psychologist(s) in this district typically spend engaged in the following activities: Designing & Implementing Interventions 0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-

5 Assessing Students Writing Reports Consulting (with families, students, staff) Attending Meetings Research (includes grant writing) Program Development (i.e., program planning & evaluation) Training (Providing & Receiving training) To the best of your knowledge, has any professional staff member, involved in direct or indirect supervision of trainees, ever been ethically sanctioned by a review board or had their license suspended or placed on conditional status by a regulatory board? Yes No (If yes, attach explanation) SERVICES OFFERED Please indicate all of the following that are offered at your site: Preschool Programs Crisis Response Team Threat Assessment Team Functional Behavior Assessments Prereferral Intervention Teams (Teacher/Student Assistance Teams) Family resource center(s) Support Groups Grant Office/Department Teacher Consultation Parent Consultation Program Evaluation Staff training/in-services Research Program Development Prevention Activities/Initiatives Alternate School(s) Charter School(s) Neuropsychological Evaluations Individual Therapy Group Therapy Family Therapy Substance Abuse Counseling Medication Management Collaboration w/ Offsite Providers School-Wide Screenings Case Management Multidisciplinary Collaboration (on site) Community Education/Outreach Vocational/Career Counseling Specialized Behavioral Interventions Social Skills Training Parent Training (e.g., ABA therapy) Curriculum-Based Assessment Programs for ESL Gifted/Talented Programs District-sponsored tutoring students

6 Provide a detailed description of the services to be rendered by the trainee: List specific training outcomes of this field placement (e.g., knowledge sets and skill proficiencies to be acquired): Describe specific methods which will be used to build trainee s competencies in skill areas listed above: POPULATION SERVED Indicate which age ranges will be served by the practicum/intern trainee (check all that apply) Preschool Elementary Middle High Postsecondary Indicate the primary work appointment for the trainee: Preschool Elementary Middle High Postsecondary Alternate School Central Office* *If Central Office is selected, please provide a description of what types of schools and the age ranges of students trainee will serve: Approximately what percentage of the trainee s time will be spent in special education-related activities (assessment, eligibility meetings, etc.)? %

7 SPECIFIC TRAINING ACTIVITIES Approximately how many of the following types of school psychology services will the trainee have the opportunity to complete? (This is an estimate and it is expected that trainee s experiences will vary, depending on their strengths/weaknesses, level of training, interests, and opportunities within the training year). Initial Evaluations Functional Behavior Assessments Re-Evaluations Behavior Intervention Plans Social/Emotional Assessments Individual Therapy Cases Treatment Plans Family Therapy Cases Group Therapy Sessions Ongoing Consultation Cases Other (Specify) Other (Specify) TRAINING RESOURCES Please describe the method used to ensure access to required materials needed for on site training. (Note: Ensuring access to materials is a collaborative venture between the learner & the training site. Trainees should understand that many resources will be shared. Trainees may also be asked by districts to use their own resources, where relevant. Trainees are responsible for demonstrating below that, between the district and their own materials, there are sufficient resources to accommodate a practicum/internship position). Assessment Instruments _ Testing Rooms in the Schools Therapy Materials _ Computer _ Onsite Internet Access _ Assessment Protocols _ Office Space (Shared is Expected) _ FUNDING How are school psychology services funded in this district? General Budget Special Education Funds Grant Other (specify ) Is this field training position:

8 Fully Funded? Partially Funded? Volunteer Position? SITE SUPERVISOR (*Attach a copy of site supervisor s vita or resume at the end of this application) Primary Supervisor (Must be a credentialed school psychologist) Name & Title: Address: Office Phone: Other Phone: List the following information for each degree held by the primary site supervisor: (Degree) (Field/Major) (University) (Date Awarded) (Degree) (Field/Major) (University) (Date Awarded) (Degree) (Field/Major) (University) (Date Awarded) List the state(s) where credential from state(s) department(s) of education are held (note: credentials must be for unrestricted practice of school psychology): Please which (if any) of following additional credentials are held by this individual (if relevant): Credentialed by state board of examiners NCSP (Nationally Certified School Psychologist) Doctoral Degree (Ed.D., Psy.D., Ph.D.) Licensed as a health service provider ABPP Fellow in School Psychology Other (Specify: ) How many total years has this individual been practicing as a credentialed school psychologist? (minimum= 4) in their current position in the district? (minimum= 2) years years How many school psychology practicum trainees has this individual supervised? How many school psychology intern trainees has this individual supervised? Other supervision experience

9 PROPOSED METHOD OF SUPERVISION Please indicate which of the following methods are used to evaluate trainee progress and mastery of skills in the practicum or internship experience (Mark all that apply): Individual, face-to-face supervision Group, face-to-face supervision Individual, remote supervision (phone, internet) Group, remote supervision (tele/video conference, satellite) Classroom education/training Directed study (e.g., assigned readings) Audiotape review Videotape review Direct observation of assessment Direct observation of therapy/intervention Direct observation of consultation Direct observation during multidisciplinary team meetings Role Playing Co-therapy with trainee Presentations/Case Conferences Review of case notes Other (Specify ) SUPERVISOR AVAILABILITY Will the supervisor be available to the trainee at all times while the trainee is on site? Yes No If No, please explain What is the maximum number of trainees the supervisor will oversee for the duration of this learner s training experience? SUPERVISION SCHEDULE List the days and hours that individual supervision will be provided: List the days and hours that the primary supervisor will be on site: Provide contact information for a secondary supervisor: (This individual could be a director of special education, principal, superintendent, or other person to whom the trainee will be accountable) Name & Title: Degrees/Credentials: Address: Office Phone: Other Phone:

10 SCHOOL PSYCHOLOGY TRAINING AGREEMENT The School of Psychology, Capella University Agrees: 1. To assign a Capella University faculty liaison to facilitate communication among the University, the learner, and the site supervisor. 2. To provide the site supervisor with the following support materials: A copy of a Manual of Supervised Field Experiences that describes practicum and internship requirements of Capella University All evaluation forms required to assess the performance of field trainees To monitor the progress of the learner during the supervised field experience via a weekly online seminar 3. To maintain regular contact between the faculty liaison and site supervisor to consist of no less than electronic contact at the beginning, middle, and end of the supervised field experience. 4. To notify the learner that he/she is responsible for complying with all policies and procedures governing trainees at the site. 5. To provide immediate consultation with the faculty liaison should disagreements arise between the learner and the site supervisor (acknowledging that the site supervisor has primary authority for all activities of the learner at the site). 6. To assure that the instructor-of-record for Practicum and internship will assign a satisfactory or nonsatisfactory grade upon receipt of all documentation and evaluation forms from the site supervisor, which is to occur no later than 30 days following the end of the supervised field experience. The Practicum/Internship Site Agrees: 1. To assign a site supervisor(s) who is a fully credentialed school psychologist with at least 4 years of school psychology-related experience, and who has been in their current position as a school psychologist with your district at least 2 years. 2. To provide a curriculum vitae of the site supervisor(s) to the Training Department. 3. To provide opportunities for the learner to engage in a variety of appropriate training activities under the supervision of a credentialed school psychologist. 4. To provide the learner with adequate workspace, telephone, office supplies, and staff support to conduct professional activities appropriate to the practicum or internship. 5. FOR INTERNS: To provide the learner with at least two hours of scheduled, face-to-face supervision each week that involves the examination of the learner s work via the use of either audio/video tape, review of case records, observation, or collaborative service delivery. 6. FOR PRACTICUM TRAINEES: To provide the learner with at least one hour of scheduled, face-to-face supervision each week that involves the examination of the learner s work via the use of either audio/video tape, review of case records, observation, or collaborative service delivery. 7. To provide an opportunity for the learner to accrue at least 350 contact hours in the discipline for practicum trainees, and 1200 contact hours in the discipline for intern trainees 8. To review trainee s activities at the conclusion of field training and verify hours were completed

11 9. To review and initial trainee s weekly contact log, service log (upon field training completion), and weekly supervision log. 10. To inform the trainee of local school district policy and procedure pertinent to their field training activities 11. To collaborate with the school psychology department chair (or designee) to provide site and university coordination of the field training experience 12. To provide formal evaluation of the learner on forms established by Capella University s School of Psychology at periodic intervals in field training, as well as upon completion of all required hours. 13. To periodically conduct formal observations of trainee while engaged in direct service delivery and complete observation form provided by Capella. 14. To notify the training department immediately if there are any changes to the contract, including dates, hours, supervision, etc. The Learner Agrees: 1. To complete prerequisite coursework and experiences prior to initiating field training, which may require additional readings, classes, and/or assignments be completed (at the discretion of the site supervisor, Capella faculty, and the Director of Training). Learner agrees to fulfill prerequisites in their entirety in order to ensure readiness for field training. 2. To immediately notify the training department if there are any changes to the contract including dates, hours, supervision, etc. 3. Abide by all rules and regulations issued by the state department of education in the state in which they are completing field training 4. Uphold the ethics code of the National Association of School Psychologists 5. Follow all relevant policy, procedure, rules, and standards of the school district 6. Maintain a log of activities 7. To fully participate in the online course room component of the field training course and completed all related assignments 8. To notify the training department if there occurs an absence of seven (7) days or more from the training site 9. Participate in site training (e.g., pertaining to local policy & procedure) offered by the district which may be required for fulfilling practicum/internship duties 10. To be responsible to obtain additional training and/or education, as deemed necessary by supervisor, Capella faculty, or Director of Training, to conduct activities required at the training site

12 Parties to the Field Training Agreement: This agreement, dated, is made among the following parties: The practicum/intern learner (the learner ), named, The practicum/intern site (the site ), named, And the School of Psychology, Capella University. Term of the Agreement: This agreement shall be effective from / / to / /. A minimum of total hours will be logged during the supervised field experience, of which a minimum of hours will be devoted to individual supervision and at 50% of the hours will be devoted to the delivery of psychological services or other appropriate psychological activity. Site Supervisor Agreement I,, the primary supervisor assigned to this learner, agree to provide professional supervision to the standard expected by the National Association of School Psychologists, the state department of education, and as defined by the Psychology Program at Capella, for this supervised field experience. I agree to adequately evaluation this learner s performance at the end of the supervised field experience and to submit all required forms no later the end of the quarter in which the field training experience ends. I understand that Capella University does not compensate site supervisors for their supervisory services and that any such compensation is provided by the site. This application will be approved by the Director or Associate Director of Training when all documentation required as part of this application have been received and the primary supervisor has accepted the assignment. This agreement is valid when all signatures appear below. Once all individuals have signed this form, it should be mailed to: Training Department, Harold Abel School of Psychology Capella University 225 South Sixth St. Minneapolis, MN The learner is not allowed to register or begin field training until receiving written confirmation from Capella s Directory of Training or appointee of the Director.

13 SIGNATURE PAGE: Learner Signature Date Learner Name (print) Date Capella- School Psychology Director Signature Date Capella- School Psychology Director Name (print) Site Supervisor Signature Date Site Supervisor Name (print) Date Capella Director of Training/Designee Signature Date Capella Director of Training/Designee Name (print) ADDENDUM: Learner is required to attach a copy of the following to this application: 1. Notarized statement (acknowledging no criminal background- Form D) 2. Learner s resume/vita 3. Site supervisor s resume/vita 4. Proof of professional liability insurance 5. Writing sample- (integrated psychological assessment report that includes a minimum of IQ, academic achievement, summary, and recommendations)

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