Department of Counselor Education P & I Clinical Site Development Site Information Form

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1 Department of Counselor Education P & I Clinical Site Development Site Information Form Instructions for the Site Representatives: Please type your responses to the following questions in the fields provided. Use the tab key to move between fields. Please fax to (352) or mail to the following address: Assistant Clinical Coordinator; Department of Counselor Education; 1215 Norman Hall; POB ; Gainesville, FL If you have questions, please contact or (352) , Ext Agency Demographic Information Agency Name Mailing Address City State Zip Code Physical Address City State Zip Code Directions to Site Days and Times Facility is Open for Students to See Clients Phone Fax Website Primary Site Host Demographic Information Name Job Title Highest Earned Degree License No University of Florida Employee Work Phone Profession SSN (Required for Tuition Waiver) Work Work Fax Page 1 of 3

2 Alternate Site Host Demographic Information Name Job Title Highest Earned Degree License No University of Florida Employee Work Phone Profession SSN (Required for Tuition Waiver) Work Work Fax Clinical Information Please provide a brief description that would help introduce your site to students. Select the appropriate level(s) of experience for students at your site. Practicum Internship Select the appropriate clinical specialization(s) for students at your site. Mental Health Counseling Marriage & Family Counseling School Counseling & Guidance Identify any prerequisite coursework or clinical experiences you require of students. Minimum semester commitment Maximum number of students per semester Identify and describe characteristics of population receiving services at your site Identify counseling modalities used at your site Identify and describe professional development opportunities available at your site. Page 2 of 3

3 Clinical Supervision, Observation, and Taping Opportunities Select the clinical supervision opportunity(ies) that are available at your site. None Individual Group Students are required to tape their work for supervision. If taping is not possible at your site, students must be observed for the equivalent number of sessions. Is taping allowed at your site? Check all that apply. Select all available recording equipment No Yes-Audio Yes-Video Audio Video Students must provide own equipment Select if observation of other professionals in practice is available. Application Process Describe application instructions, including contact names and information. Yes No Do you offer financial compensation to practicum and Yes No internship students? Steps to becoming and maintaining an active clinical site with the Department of Counselor Education Step Completed Date Completed Complete and submit Site Information Form annually or whenever Site Host changes Submit current Resume or Curriculum Vita for each Site Host Schedule a Site Visit or telephone Site Visit annually with the Clinical Coordinator Current Site Information Form Form completed by Date completed Thank you for your interest in working with our Department and Students! Please print form (or if you are able to save it in Adobe Professional) and send it to the Assistant Clinical Coordinator. Questions? Contact , Ext. 400 or Assistant Clinical Coordinator Department of Counselor Education 1215 Norman Hall POB Gainesville, FL Page 3 of 3

4 Principal Investigator/Program Director (Marrero, Lucy G.): BIOGRAPHICAL SKETCH NAME Marrero, Lucy G. POSITION TITLE Clinical Coordinator, Child Adolescent Program EDUCATION/TRAINING INSTITUTION AND LOCATION DEGREE (if applicable) YEAR(s) FIELD OF STUDY University of Kentucky BA cum laud 1973 Psychology State University of New York PhD 1977 Psychology Poughkeepsie State Hospital Practicum Study Inpatient adult, child, adol. Bluegrass Mental Health/Mental Retardation Center Lexington, Kentucky Doctoral Intern Child/Adol, Adult, Substance Abuse Taylor Manor Hospital, Ellicott City, Maryland Post-Doctorate Clinical Psychology William Howard Taft University, Fountain Valley, CA Jurisdoctorate study A. Positions and Honors. Positions and Employment Clinical Coordinator, Child Adolescent Program, Vista, Gainesville, Florida Psychologist, Vista, Gainesville, Florida Teacher Undergraduate classes in Psychopathology for Law Enforcement, Abnormal Psychology, Psychotherapy, Santa Fe Community College, Gainesville, Florida 1991 Psychotherapist, Lexington/Richland Co. Alcohol and Drug Abuse Center, Columbia, SC Director, Psychotherapy Institute. Director of outpatient clinic Chief Psychologist, Austin Child Guidance and Evaluation Center, Austin, Texas Adjunct Faculty, University of Texas, Austin, Texas Chief Psychologist Child/Adolescent Unit, Harriet Cohn Mental Health Center, Clarksville, TN Adjunct Faculty, Vanderbuilt University APA approved Post Doctorate in child/adolescent psychology, Taylor Manor Hospital, Ellicott City, MD Intern, Blue Grass Mental Health Comprehensive Care Center, Lexington, KY Director, Schenectady Youth Project, Schenectady, New York Teach undergraduate courses in Psychology and assist with statistical research, State University of New York at Albany, New York Volunteer Practicum Student Mental Health Worker in children s psychiatric unit, Poughkeepsie State Hospital, Poughkeepsie, New York Supervisor, Office of Economic Opportunity Program for disadvantaged and/or neglected teenagers. One year grant sponsored by OEO. Community Services 1995 Appointed to Alachua Volunteer Council 1988 Volunteer of the Year, Austin, Texas, through Adopt a School Program 1984 Air Force Family Services Volunteer of the year for development of Operation Smooth Move B. Selected peer-reviewed publications (in chronological order). Publications 1996 Delivered paper on Service Learning and Altruism to National Social Science Convention. Published in National Social Science Journal, 1996 In Press 2000 Cross Cultural Approaches to Psychology Presentations and awards 1995 Delivered paper on Mental Health and Altruistic Volunteering to State of Florida Campus Compact 1995 Delivered paper on Service Learning and Altruism to state School to Work Conference, 1995 PHS 398/2590 (Rev. 05/01) Page 1 Biographical Sketch

5 SUSAN M. GARCIA, L.C.S.W., P.L. QUALIFICATIONS Fifteen years post-graduate clinical and administrative experience which includes expertise in developing and managing programs that treat children, adults, and families with trauma issues. Experienced court evaluator and witness for dependency court, family court, and immigration court. Court-appointed parenting coordinator and certified family mediator. WORK HISTORY 2005 Coordinator of PALS, Susan M. Garcia, L.C.S.W., P.L. Develop and oversee violence prevention and intervention programming in the schools. Supervise graduate interns and provide crisis intervention Private Practitioner, Miami Counseling and Resource Center Provide psychotherapy to children, adults, and families specializing in abuse and trauma issues, marital and divorce issues, eating disorders, depression and anxiety. Provide parenting coordination Sexual Abuse Treatment Therapist, Family Resource Center Provide individual, family, and group sexual abuse treatment to children, adolescents, adults, and non-offending family members which included intensive case management, report writing, court appearances regarding adequacy of parenting and reunification in dependency court Director of Adler Support Center, Family Resource Center Develop and manage programs designed for the prevention and treatment of child abuse. Built the building from the ground up. Management duties included programming, budgeting, staff and clinical supervision, grant writing, developing policies and procedures, public relations, marketing, and community outreach. EDUCATION MSW, State University of New York at Albany B.A., English Literature, State University of New York at StonyBrook. Florida State Licensure in Clinical Social Work, SW , 4/95. Florida State Certified Family Mediator and Parenting Coordinator. New York State Teacher Certification, Secondary English, 6/85.

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