1 TENNESSEE TECHNOLOGICAL UNIVERSITY Department Of Counseling and Psychology School Counseling Handbook Revised May, 2009
2 1 TABLE OF CONTENTS CONCEPTUAL FRAMEWORK... 2 PURPOSE OF THIS HANDBOOK... 3 PURPOSE OF THE INTERNSHIP... 3 APPLICATION PROCEDURES... 3 ROLES AND RESPONSIBILITIES OF SUPERVISORS... 5 GENERAL REQUIREMENTS... 5 RULES OF COMMON SENSE... 6 TTU PROGRAMMATIC OBJECTIVES... 7 STATE OF TN DOE OBJECTIVES... 7 PHILOSOPHICAL FRAMEWORK... 9 REQUIRED SKILLS ADDITIONAL RELEVANT INFORMATION ENDORSEMENT WORKSHEET FOR SCHOOL COUNSELING PRE K APPENDICES Appendix A Intern Contact Information Appendix B Letter to Principal Appendix C Log Sheet Appendix D Evaluation Checklist Appendix E Narrative Summary Appendix F Site Supervisor Evaluation Appendix G Informed Consent Appendix H Verification of Liability Appendix I Risk of Harm Appendix J Child Abuse Reporting Form... 27
3 2 HANDBOOK FOR SCHOOL COUNSELING Pre K - Grade 12 Acceptance into the school counseling licensure concentration requires that, students will be familiar with all aspects of the school counseling program: competency checklist for licensure, program requirements, background requirements, as well as procedures and protocols to be met before completion of the internship experience (See Appendices.) CONCEPTUAL FRAMEWORK A single conceptual framework for all teacher education programs has been defined at Tennessee Technological University. This conceptual framework serves as a common knowledge base for all programs preparing education personnel. Central to the content of this framework is the requirement that the graduate will be a competent, caring professional who can work effectively in a diverse, technological society. Graduates will demonstrate an appropriate level of scholarship, effective communication, skills of reflection that promote self-evaluation and growth, respect for diversity, and skills of collaboration with other professionals, families, and community. The Teacher Education programs of the University are designed to provide a high level of competence in general education, discipline specialization, and pedagogy (both professional and specialized professional). All programs are designed to relate theory and practice. There is a heavy emphasis on clinical and field-based experiences. Through these efforts, the adequacies of the students knowledge and skills to teach in specified areas can be determined. The school counselor preparation program incorporates this rationale to assure that candidates for licensure will acquire the specified knowledge and skills. The school counseling program prepares graduate students to perform the duties required of a counselor in Grades Pre K 12. While the instructional program in Grades Pre K 12 is the primary purpose for a school s existence, the counseling program can provide necessary support functions to help the instructional program work effectively. In both the public and private school setting, the ultimate goal is the maximum development of each student s academic potential. Other outcomes, such as the acquisition of cultural values and the development of self-esteem and social-participation skills are not only additional desirable objectives but may also assist students in the learning process. For schools to reach their student development goals, counseling graduates should be prepared to plan, organize, and implement an effective counseling program which includes services to students (counseling, assessment, advisement, consultation, and guidance), parents (consultation), teachers (consultation), and other school personnel including school administrators, school psychologists, and school social workers (consultation). Graduates of the TTU school counseling program will be able to apply the standards of the Tennessee Model for Comprehensive School Counseling. (Rev 10/05)
4 3 PURPOSE OF THIS HANDBOOK The present document is intended to introduce students to the requirements for the satisfactory completion of TTU s School Counseling concentration. Included in this document is information concerning required paperwork, processes for selection of schools and site supervisors/mentors, and suggestions for effective interaction among TTU, site supervisors and the school counseling graduate student/intern. The document will identify prerequisites for internship at both the MA and EdS levels. No one source can hope to prepare an intern for all situations at a placement site. PURPOSE OF THE INTERNSHIP The internship is a learning experience that builds upon the coursework, state requirements for licensure and culminates in the development of a fully functioning school counselor. As it is with other licensure preparation programs, the school counseling internship experience serves as the pinnacle of counselor preparation. The intern is expected to assume, as much as possible, the role of a professional counselor with the guidance and feedback of the supervising/mentor counselor. The internship is designed to relate theoretical and academic learning to real life professional experience. The 600 hours of experience is designed to provide the intern with practical experiences in school settings with students Pre K through Grade 12 and is constructed to meet state requirements by having the intern serve 300 hours at the elementary and 300 hours at the secondary school levels. This direct internship experience includes, but is not limited to: individual counseling, group work, developmental classroom guidance, and consultation. Process/ procedures and protocols, including forms to be completed during the internship as verification, will be discussed, monitored and reviewed by the TTU advisor, school counseling program coordinator and/or the instructor assigned to the internship course. The internship experiences allow the intern to receive feedback about his/her skills, professional behavior, and knowledge and to help him/her prepare for continuous improvement in his/her chosen profession. APPLICATION PROCEDURES 1. School counseling graduate level students are required to have adequate and appropriate preparation (a minimum of 12 background credit hours) at the undergraduate level by having taken approved background courses as prerequisites. The courses are to be approved by the faculty advisor and should include, but may not be limited to, coursework in the following: curriculum development, special education, learning theories and social foundations. These approved courses are transferred to the Program of Study as background courses, not to be counted toward graduate degree. 2. For those students who are able to transfer those background courses, as outlined in #1 above, but who have no experience in the school setting, a 1 credit hour orientation class will be required the first semester. This course will meet state requirements and will also allow the student to obtain necessary experience in the school setting.
5 4 3. Both the Graduate Catalog and the policy of the Department require the interns to complete a minimum of the core counseling courses before enrolling in an internship course. Those courses are: Orientation to Counseling (or equivalent), Theories and Techniques, Advanced Skills (or Practicum) and Group Counseling. Usually, students are near completion of their program of study before beginning an internship for any of the counseling programs. 4. Before placement at the Ed.S. level, the requirements for the MA in School Counseling Pre K-12 must be met. 5. Students must apply for internship the semester before taking the course. In general, placement may be made only during Spring and Fall Semesters. The deadlines are the week before final examinations. 6. It is recommended that students make arrangements to take the Specialty exam of the Praxis during their internship. When notice is received that the student has passed, it is critical that an appointment be made with the TTU, College of Education, Office of Teacher Education, to ensure that all forms and state requirements are met and that the paperwork can be completed for licensure. 7. The counseling faculty will work with the student in arranging placements at the most appropriate sites. Final placement is subject to approval by the university supervisor, the placement school counselor, and the placement school administrator/principal. NOTE: The policy of the Counseling and Psychology Department is to place interns in diverse settings as per state requirements. 8. Students will be provided a course syllabus, required forms and explanations of expectations to be completed by the TTU faculty supervisor and/or departmental advisor. 9. As outlined in the Graduate Portfolio, all interns must provide proof of liability coverage prior to school placement. This information is also presented in the Orientations or Introduction to Counseling course. 10. Students must also know the ethical and legal guidelines that are applicable to the school setting. The American Counseling Association s ethical guidelines and legal requirements are discussed in course offerings and intern meetings. Copies are available on-line for student review.
6 5 ROLES AND RESPONSIBILITIES OF SUPERVISORS University Supervisor. The university supervisor assists students in completing the internship experience. The supervisor will provide timely supervision, critique student work products, consult with the mentor counselor concerning the intern s progress, assure all required forms are completed, assess performance and assign the course grade. In short, the university supervisor will assist the intern to meet university and state requirements and to prepare the intern for licensure. Site Supervisor/Mentor Counselor. Site supervisors (sometimes called mentor counselors), are licensed, experienced professionals in the school systems in which the intern is placed. These site counselors must be licensed by the Board of Education. They must have a minimum of two years experience as licensed, practicing school counselors. As much as possible, counselors are expected to be active in professional organizations and professional community activities. The mentor counselors will be selected by the university/faculty supervisor in cooperation with the school administrators; the student s needs relevant to location, previous knowledge of the school and/or staff, will be taken into consideration. The site supervisor counselor is to provide on-site supervision, guidance and mentoring to the intern. The mentor will assist the intern in completing the experience at that site, discuss progress, communicate with university supervisor as needed and participate in the evaluation of the student. GENERAL REQUIREMENTS 1. Ideally, the MA and Ed.S contact hours will be completed during the course of a semester. However, TTU is cognizant of the fact that a majority of students are not full-time students. Part-time students must register for the internship course before starting their placement. Those students not completing internship requirements during the semester will be awarded a grade of I. The intern will have one year to remove the I before it turns into an F. (See University Catalog). All students, both full and part-time students must work closely with their site and university/faculty supervisors to ensure all requirements are met. 2. Prior to placement, the intern will have an initial interview with the mentor counselor at the school site. This meeting may be arranged by either the student or the faculty supervisor. Faculty supervisors must have prior knowledge of this interview to help prepare the student for this face-to-face at the selected site. 3. The intern and supervising school counselor will mutually develop a schedule for the experience. Interns are required to keep a log of their activities which will be verified by the mentor counselor and presented to the university supervisor. Examples of logs are available from the university supervisor and will be provided before the internship begins. 4. The intern is expected to complete a number of on-site assignments required by the site and the university supervisor. These will be clearly communicated.
7 6 5. The intern will provide the mentor counselor and the university supervisor with a schedule of the dates of the semester as well as dates (holidays, classes, etc.) when the student will not be available to be present at the site. 6. The intern will spend a minimum of one hour per ten contact hours with the mentor counselor for supervision. If any concerns arise concerning the supervision, the student should first meet with the mentor counselor. Should problems persist, the intern should relate these concerns to the university supervisor. Meetings with the site supervisor should be documented in the log. 7. The university supervisor will visit the site/sites to meet with the mentor counselor and intern during the term. During such visits, the university supervisor will discuss the intern s progress and may wish to observe the intern in his/her activities. 8. The intern is required to meet on a regularly scheduled basis in a group setting with the university professor, as assigned 9. Evaluations of the intern will be completed by the site supervising/mentor counselor near the end of the intern s experience at that site. The forms will be explained and given to the intern at the beginning of the experience so evaluation criteria are clear. The intern will be responsible for distribution of appropriate forms. 10. The intern will also evaluate his/her supervising mentor counselor and will document his/her experience as assigned by university supervisor. RULES OF COMMON SENSE Counselors are role models. The intern will dress appropriately and in accordance with the site dress codes. The intern is a professional and will behave accordingly. He/she will be punctual and meet all obligations in a professional manner. If possible, the intern should go to the placement site well in advance of the time the experience begins to become acquainted with co-workers and the placement s procedures. The intern should become involved with as many of the site s activities as possible. These are unique learning opportunities that will add to one s experience.
8 7 TTU PROGRAMMATIC OBJECTIVES TTU s school guidance and counselor education program for Pre K 12 counselors includes the following essential objectives: 1. a thorough general education as a foundation for professional studies at the graduate level; 2. field experiences which allow the student to apply and integrate professional knowledge into the work context; 3. an integrated and sequenced set of courses and learning experiences that provide time for the acquisition, practice and development of the skills, understandings, and dispositions which are the outcomes of the program; 4. a foundation in the theories of counseling; 5. a foundation in child and adolescent psychology; 6. a foundation in experimental design, statistics, and computer analysis; 7. a foundation in educational and psychological measurement; 8. counseling skills that are supported by current research on counseling; 9. the development of skills in group counseling and guidance, including the use of technology-based resources; 10. a thorough knowledge about careers and the process of career development; 11. a system of student evaluation, which consists of formative and summative evaluation in courses, on-site supervision, and a comprehensive evaluation near the completion of an individual s program. STATE OF TN DOE OBJECTIVES The Department of Education specifies that all PreK-12 school counseling interns are prepared for licensure in accordance with the following knowledge and skills, obtained during graduate course work, field experiences and professional practice: (Standards adopted/revised 4/06) 1. Ability to apply knowledge from the areas of human growth and development and learning theories; to identify learning problems; and to assist teachers and parents in responding to counseling and guidance interventions with students. 2. Understanding the process of social and cultural change with respect to various racial, gender, and ethnic groups, and knowledge of differing cultural and lifestyle
9 8 patterns. Ability to develop plans and programs to prevent person and substance abuse, discrimination, and dropping out of school. 3. Understanding of the philosophical basis underlying the helping process. Ability to facilitate student growth and development and positive systemic change through counseling, advocacy, leadership, collaboration, and consulting activities, including contributing to the development and implementation of individualized educational programs (IEPs) for students with special needs. 4. Ability to lead large and small group counseling and guidance activities related to personal and interpersonal growth, self-help and problem solving, and career development. 5. Understanding changes in society and technology and the influence of changes on work and learning. Ability to develop and implement a comprehensive career development program. 6. Ability to assist in curriculum advisement and career counseling using a variety of materials, strategies, and technologies. 7. Understanding of appropriate tests and other assessments to assist students and their parents in making effective educational, social, and career decisions. Ability to use group-administered educational and psychological measurement and appraisal instruments. 8. Ability to plan, manage, deliver, and evaluate a comprehensive PreK-12 professional school counseling program. Understanding of research and research design. Ability to conduct research and evaluation projects related to the outcomes of professional school counseling services. 9. Understanding of the ethical and legal standards of school counseling professionals. 10. Ability to collaborate with parents, teachers, school social workers, school psychologists, family resource center staff, and other community partners in meeting student needs. 11. Ability to inform students, teachers, parents, and the community about the purposes and activities of the professional school counseling program. 12. Ability to work with parents and conduct parent education activities. Ability to use community resources and referral processes, and develop effective partnership arrangements with community agencies.
10 9 PHILOSOPHICAL FRAMEWORK The purpose of a counseling program within an educational setting, such as the public schools, is to promote and enhance the learning process for all students. The previously outlined TTU objectives, as well as the Tennessee State Department of Education s standards, are in accordance with the National Standards for School Counseling Programs as defined by ASCA to facilitate student development and preparation in three main areas: academic development, career development and personal/social development, as this is the primary duty and role for the school guidance counselor. Following are the nine national standards: I. Academic Development Standard A Students will acquire the attitudes, knowledge and skills contributing to effective learning in school and across the life span. Standard B Students will complete school with the academic preparation essential to choose from a wide range of substantial post-secondary options, including college. Standard C Students will understand the relationship of academics to the world of work and to life at home and in the community. II. Career Development Standard A Students will acquire the skills to investigate the world of work in relation to knowledge of self and to make informed career decisions. Standard B Students will employ strategies to achieve future career success and satisfaction. Standard C Students will understand the relationship between personal qualities, education and training, and the world of work. III. Personal/Social Development Standard A Students will acquire the attitudes, knowledge, and interpersonal skills to help them understand and respect self and others. Standard B Students will make decisions, set goals, and take necessary action to achieve goals. Standard C Students will understand safety and survival skills.
11 10 REQUIRED SKILLS The school guidance counseling intern will both demonstrate the skills learned during his/her course work and develop professionally. The 600 required internship hours will include placement at Pre K-4, 5-8, and 9-12 levels with licensed experienced counselors. The specific skills to be demonstrated by the intern and evaluated by joint efforts of the site supervisor and the university supervisor are listed below: The intern will: 1. Display appropriate ethical, professional, and legal behaviors. 2. Demonstrate the ability to assist in curriculum advisement and career counseling. 3. Demonstrate the ability to lead large and small group counseling and guidance activity related to personal and interpersonal growth, self-help, and problem solving and career development. 4. Demonstrate the ability to use appropriate tests and other assessments to assist students and their parents in making effective educational, social, and career decisions. 5. Demonstrate the ability to work with teachers, school social workers, school psychologists, and family resource staff in meeting student s needs. 6. Demonstrate the ability to inform teachers, students, and the community about the purposes and activities of the school counseling program. 7. Demonstrate the ability to apply knowledge from the areas of human growth and development and learning theories to identify learning problems and to assist teachers and parents in responding to counseling and guidance interventions with students. 8. Demonstrate the ability to develop plans and implement programs to prevent person and substance abuse, discrimination, and dropping out of school. 9. Demonstrate the ability to facilitate student growth. 10. Demonstrate the ability to work with parents and conduct parent education activities. 11. Demonstrate the ability to use community resources and referral processes, and develop effective partnership arrangements with community agencies. 12. Demonstrate the ability to counsel and work with people of varying backgrounds. 13. Demonstrate the ability to counsel effectively.
12 11 ADDITIONAL RELEVANT INFORMATION Insurance: All interns must have liability insurance before placement. Documentation: The intern will keep a log of all activities, as defined by the university supervisor. The supervisor will verify the log and evaluate the intern s performance with special reference to the listed objectives. Supervision: The intern is expected to meet with the university supervisor as assigned each week of the internship in a group setting. Individual meetings will be scheduled per university schedule. These contacts will be listed in the intern s log. The site supervisor is expected to spend an average of one contact hour per week with the intern. However, contact is usually more frequent than this. These contacts will also be listed in the intern s log. A minimum of one visit by the university supervisor will be conducted per site assignment. More visits may be conducted as needed. These visits will be listed in the intern s log.
13 12 VERIFICATION FORM FOR SCHOOL COUNSELING PRE K 12 TENNESSEE TECHNOLOGICAL UNIVERSITY NAME T # Last First Middle The above named individual has satisfactorily demonstrated competencies in the areas of school guidance counseling as defined by the Tennessee Department of Education standards by completion of appropriate courses and/or by special assessment. Following are suggested coursework; alternatives may apply and must be recorded appropriately by TTU advisor or school counseling program coordinator. Signature of Person(s) Background Courses Verifying Competencies Completion Date PSY 4100/5100 Child Psychology PSY 4150/5150 Psy of Personality PSY 4200/5200 Adolescent Psy EDPY 5850 Orientation/Experience Others to be counted as accepted background: Required Coursework and/or Competency Topic EDPY 6300 Intro to Counseling Services: Ethical and Legal Foundations EDPY 6310 Educational Statistics EDPY 6320 Group Counseling EDPY 6330 Organization and Administration of School Counseling Programs EDPY 6360 Counseling Theories EDPY 6362 Counseling Techniques
14 13 EDPY 6380 Intro to Multicultural Counseling EDPY 6410 Career Development EDPY 6800 Advanced Skills: Practicum in Counseling EDPY 6830 Internship/School Counseling Site of Internship 300 hours Site of Internship 300 hours EDPY 6900 Problems in Ed Psychology OR EDPY 6990 Research and Thesis EDPY 7170 Consultation in the Educational Setting EDPY 7200 Advanced Ed Psychology FOED 6920 Educational Research PSY 5250 Intro to Psychological Testing SPED 6010 Survey of Disability Characteristics, Procedure & Methods in SPED CUED 6010 Curriculum Development & Evaluation Listing of Additional Coursework Verifying Competency:
15 14 ENDORSEMENT WORKSHEET FOR SCHOOL COUNSELING PRE K 12 TENNESSEE TECHNOLOGICAL UNIVERSITY COOKEVILLE, TN NAME Last First Middle Maiden Social Security Number (DOE State requirement) Endorsement: School Counseling Pre K 12 The above named individual has satisfactorily: 1. demonstrated competencies in the areas of school counseling defined by the Tennessee Department of Education by completion of appropriate courses and/or by special assessment; 2. furnished evidence of appropriate experience in the schools. It is recommended that the above applicant be endorsed as a Pre-K-12 School Counselor having satisfactorily demonstrated all the competencies included in the approved program at Tennessee Technological University, Department of Counseling and Psychology. Coordinator, School Counseling Licensure Committee Date Chairperson, Department of Counseling and Psychology Date Director, Teacher Education Date
16 15 SCHOOL COUNSELING INTERNSHIP APPLICATION Name T Number Address Day Phone Evening Phone Date Term of Enrollment Enrolling in: EDPY 6830 EDPY 7830 BOTH Will be: FT Intern PT Intern I have completed prerequisites YES NO If no, explanation and/or plan of action: Preferred Site: Hours of Availability: List any special factors or considerations that would effect placement (disability, etc.) Intern Signature Date Supervisor Signature Date
17 APPENDICES 16
18 17 Appendix A INTERN CONTACT INFORMATION Tennessee Technological University Department of Counseling and Psychology Please complete during the first week of the semester; keep one copy and make copies for your Site Supervisor and your University Supervisor. Student s Name: Address: Home Phone: Cell Phone: School Phone: Are you working in another job during the Internship? Pleases give information such as: Employer: Phone Number: Hours per week: Expected Graduation Date: Schedule of Internship Placement: School Name and Address: TTU Internship Supervisor:
19 18 Appendix B Dear This letter is to introduce, a graduate student in the Department of Counseling and Psychology at Tennessee Technological University. He/she is working toward obtaining licensure as a school counselor and must meet the State Department of Education s 600 pre-professional internship hours. Placement must reflect experiences at both the elementary and secondary levels and we suggest 300 hours completed at each of these levels. With your approval, the above named intern will: 1. Provide for liability insurance and provide verification to faculty intern supervisor, 2. Maintain ethical guidelines as described by professional counseling organizations and state/federal mandates, 3. Assist the school counselor as specified in licensure requirements, 4. Maintain a log of hours completed in designated activities, and 5. Obtain mid-term and final evaluations completed by the school counselor, who will also serve as site supervisor for this internship. Please note that your school counselor has tentatively approved this placement for the semester. This tentative approval is, of course, pending your agreement. If this arrangement is not satisfactory or if you have any questions relevant to this placement, please feel free to contact me. If you agree to this arrangement, the above named student intern will be placed at your school from until. The intern will complete the internship hours under the supervision of the school counselor. Thank you for the opportunity to be of service to your school counseling program in this manner. We appreciate the cooperation between our school counseling program and our schools. Again, please feel free to contact me with any questions. Sincerely, Dr. Sherrie Foster, Assistant Professor School Counseling and Guidance Coordinator Counseling & Psychology Department, TTU
20 19 Appendix C SCHOOL COUNSELING INTERNSHIP LOG SHEET Name: School: HOURS Put Date Below each Day Mon. Tues. Wed. Thur. Fri. Sat. Sun. Total. Tasks Covered Individual Counseling Group Counseling Classroom Guidance Assessment/ Testing Faculty/Staff Consultation Parent Consultation Referrals Professional Development Program/ Case Planning On Campus Supervision Site Supervision Peer Reviews/ Critiques Other (Specify) Total Hours Signature of Site Supervisor Signature of Intern
21 20 Appendix D INTERN EVALUATION CHECKLIST Name of Intern: Site of Placement: Please rate intern using the following scale in each of the listed competencies: 1. Outstanding 2. Good 3. Average 4. Below Average 5. Not Satisfactory 6. Not Observed The intern: 1. Displayed appropriate ethical, professional and legal behaviors. 2. Demonstrated the ability to assist in curriculum advisement and career counseling. 3. Demonstrated the ability to lead large and small group counseling and guidance activity related to personal and interpersonal growth, self help, and problem solving and career development. 4. Demonstrated the ability to use appropriate tests and other assessments to assist students and their parents in making effective educational, social, and career decisions. 5. Demonstrated the ability to work with teachers, school social workers, school psychologists, and family resource staff in meeting student needs. 6. Demonstrated the ability to inform teachers, students, and the community about the purposes and activities of the school counseling program. 7. Demonstrated the ability to apply knowledge from the areas of human growth and development and learning theories to identify learning problems and to assist teachers and parents in responding to counseling and guidance interventions with students. 8. Demonstrated the ability to develop plans and implement programs to prevent person and substance abuse, discrimination, and dropping out of school.
22 21 9. Demonstrated the ability to facilitate student growth and development through both counseling and consulting activities, including contributing to the development and implementation of IEPs for students with special needs. 10. Demonstrated the ability to work with parents and conduct parent education activities. 11. Demonstrated the ability to use community resources and referral processes, and develop effective partnership arrangements with community agencies. 12. Demonstrated the ability to counsel and work with people of varying backgrounds. 13. Demonstrated the ability to counsel effectively. Signature of Site Supervisor:
23 22 Appendix E Narrative Summary of Evaluation Log Intern s Name: Period of Internship: Site: Directions: Using the Evaluation Checklist as your guide, please expand on the categories of evaluation as listed below: I. Personal and Professional Attributes: Personal Qualities, Professional attributes and Relationships, Professional Effectiveness. II. Performance of Intern: Organization of school, counseling activities, etc. III. Overall Evaluation: Unique strengths/skills, areas for improvement, professional development issues, etc. Name of Site Supervisor Signature of Site Supervisor: Date of evaluation completion:
24 23 Appendix F Site Supervisor/Mentor Evaluation Site Supervisor Placement Site Intern Date Completed PLEASE USE THE FOLLOWING SCALE IN EVALUATING YOUR MENTOR COUNSELOR: 1. Outstanding 2. Good 3. Average 4. Below Average 5. Not Good 1. He/she was available for my supervision. 2. He/she facilitated the accomplishment of the internship tasks. 3. He/she appropriately and consistently discussed my progress. 4. He/she clearly communicated assignments. 5. He/she was available when problems arose. 6. He/she was a role model for me, displaying professional attributes and skills. 7. Assigned internship activities were appropriate, for site and my own level of expertise. 8. The overall evaluation of the site placement. Additional Comments: Intern Signature
25 24 Appendix G Informed Consent I,, may be required to audio tape and/or video-tape my pre-professional counseling and/or assessment sessions to submit to supervisors who are responsible for evaluation of my skills. Any recordings may be reviewed by my site supervisor, my TTU graduate faculty supervisor and/or other graduate interns who are also enrolled in this internship course. Counseling and/or assessment procedures require consent. Please note that all information is confidential; exceptions are those listed above and any of the following: 1. It is determined that a threat of harm to self and/or others has occurred. 2. There is an indication of child abuse, to be reported under state and federal legal mandates. 3. Intern is court ordered to release information. 4. Intern has been directed, in writing, to discuss the information obtained therein with another designated party. Therefore, I,,parent/guardian of (print name of parent/guardian), agree to allow minor child to (print name of minor child) participate in pre-professional counseling and/or assessment sessions with the above named intern. I understand the above listed conditions and have resolved any questions or concerns. (Parent/guardian signature) (Intern signature) Date Date
26 25 Appendix H Verification of Liability Insurance I,, submit this (printed name of insured) verification form as proof of liability insurance. Directions: Check one and complete the information below and return to TTU Supervisor prior to beginning internship. A copy should also be placed in graduate portfolio. Personal policy/private carrier Name of Carrier: Amount of Coverage: Dates of Coverage: from to OR professional membership policy Name of Carrier: Amount of Coverage: Dates of Coverage: from to Signature of Insured Date
27 26 Appendix I Risk of Harm to Self or Others REPORT FORM TCA Title 39, as well as various professional organizations, stipulate that any/all persons with knowledge of situations posing risk of harm to self or others, including, but not limited to: threats against a person, self injury, and/or suicide risk, must report to the appropriate authorities. As a pre-professional, interns are required to meet this legal and ethical mandate, specifically while serving in the school to which he/she is assigned. This form will serve as written verification that this reporting occurs as appropriate. Directions: As an intern becomes aware of possible risk of harm to self or others, this form is to be completed and given to the site supervisor for consultation and signature. A copy of this form is then to be kept by the intern in his/her record. Victim s Name: Age: School: Grade: When was risk/threat reported? Who reported risk/threat? Summary of when/where/how risk of harm may potentially occur: Report information given to site supervisor? Yes No Report information given to other authority? Yes No Intern Signature: Date: Site Supervisor Comments: Site Supervisor Signature: Date:
28 27 Appendix J CHILD ABUSE REPORT FORM TCA Title 37: Chapter 1, Part 4, stipulates that any/all persons with knowledge of possible child abuse or neglect must report. As a pre-professional, interns are required to meet this legal mandate, specifically while serving in the school to which he/she is assigned. This form will serve as written verification that this reporting occurs as appropriate. Directions: As an intern becomes aware of possible child abuse/neglect, this form is to be completed and given to the site supervisor for consultation and signature. A copy of this form is then to be kept by the intern in his/her record. Victim s Name: Age: School: Grade: When was abuse reported? Who reported abuse? Summary of when/where/how abuse allegedly occurred: Report information given to site supervisor? Yes No Report information given to other authority? Yes No Intern Signature: Date: Site Supervisor Comments: Site Supervisor Signature: Date:
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