MFT TRAINEE FIELDWORK AGREEMENT Page 1 of 6

FORM 6

California State University, Northridge

Marital and Family Therapy Program

MFT TRAINEE FIELDWORK AGREEMENT

NOTE: PLEASE TYPE INFORMATION INTO THE SHADED BOXES BELOW.

Type of Agreement:

Comprehensive Site Placement: Site agrees to provide 500 direct service client hours over a minimum of 12 months to include 200 couple/family hours (minimum) and up to 100 alternative hours (face-to-face client centered advocacy, reflecting teams, IEP meetings, etc.). In addition, the site will allow for video recordings and provide a minimum of 100 hours of supervision with 2 hours of live supervision each semester.

Hour-Specific Site: Site unable to provide all needed hours, but agrees to provide clinical experience in accordance with BBS requirements for MFT trainees.

This form will serve as an agreement between:

Student:

Address:

Email: Phone:

Agency:

Address:

Phone:

Primary Supervisor (or Site Director) at Agency:License Type/Number:

Email: Phone:

Additional Supervisor (if applicable)License Type/Number:

Email: Phone:

and California State University, henceforth referred to as CSUN for the purpose of providing qualified supervised professional training for graduate students enrolled in the Marriage and Family Therapy Program, undertaking field placement courses at CSUN.

SCOPE

The purpose of the field placement training is to provide the student with an appropriate clinical setting to practice her/his skills in marital and family therapy.

STUDENT RESPONSIBILITIES

In order for the student to receive credit for field placement, she/he must fulfill the following requirements over a minimum of a 12-month period (note: most students are at a site for 15-18 months):

  • Complete the prerequisites for fieldwork (requirement enforced beginning Fall 2010): EPC 655 (Counseling Theories), 659A (Practicum A), 659B (Practicum B), 670A (Systemic Family Therapy), 671 (Law and Ethics), and 672 (Diagnosis).
  • Participate at this field placement site for a minimum of 10 hours per week and a maximum of 25 hours per week.
  • Conduct500 total hours of direct service hoursover a 12-month (minimum) period. These hours must include 200 hours (minimum) of couple and family therapy and may include up to 100 hours of the 500 may be Alternative Clinical Hours (such as face-to-face client centered advocacy, IEP meetings, reflecting teams, or other CSUN-approved clinically relevant experience)
  • 100 hours of supervision in accordance with BBS requirements (weekly group and/or individual)
  • “Live” supervision: Students are required to receive live supervision by site supervisors (2 hours per semester) and university faculty,which may include (a) co-therapy with an experienced clinician, (b) supervision using live media (e.g., video recording), and/or (c) supervisor observing student’s session.
  • Obtain clinical experiences that enablethem to assess and diagnose
  • Write progress notes and treatment plans
  • Provide referrals to community resources
  • If over 50% of student’s therapy is conducted in another language, the individual supervisor must speak that language or have regular access to consult with a supervisor who does speak the language. Also, some of the student’s case load should be with English as well as non-English speaking clients.

The student is responsible for:

  • Finding and securing a field placement site by the end of the first month of EPC 659P. This agreement must be approved and signed by a university representative prior to seeing clients.
  • Having the on-site supervisor complete the BBS form Responsibility Statement for Supervisors of a MFT Intern or Trainee, available from
  • Having the supervisor complete the BBS Hourly Log Form ( the CSUN Log form ( each week.
  • Completing the university paperwork which includes a personalized agreement (Form 6; ) and provide the university with the fieldsite supervisor’s email address and ensuring that the fieldsite supervisor receives and completes the online evaluation of the student toward the end of each semester (Form 6A; ).
  • Secure and maintain malpractice and personal liability insurance.

Expectations:

The student will be held accountable and responsible for her/his professional conduct at the field placement site, which includes:

  • Follwing all university and agency guidelines.
  • Adhereing to the professional codes of ethics set forth by the American Counseling Association and American Association for Marriage and Family Therapy and following all California laws that apply to the practice of marriage and family therapy.
  • Being open to feedback from fieldsite supervisors and university faculty.
  • Dressing professionally at all times when at the field placement.
  • Arriving on time for supervision and 10-15 minutes prior to scheduled client sessions.
  • Completing progress notes each day before leaving the site.
  • Communicating concerns and problems to the onsite supervisors and university faculty when they arise and monitoring areas of concern closely to prevent problems from escalating.
  • Handling cancellation of sessions due to illness or emergency per Agency policy.
  • Requesting vacation and holiday time off in a timely manner.
  • Monitoring and managing personal issues that may interfere with theability to provide professional services to clients or otherwise affect their performance.

CSUN RESPONSIBILITIES

Each student will be enrolled and meet weekly with a practicum instructor who will oversee the fieldwork experience and provide clinical training and will review live vidoetapes of student’s sessions at the site. The fieldwork instructor will make a site visit in the first or second semester of placement and will help mediate any problems that arise during the placement between the student and supervisor.

SUPERVISOR AGENCY RESPONSIBILITIES AND QUALIFICATIONS

By signing below, the Primary Supervisor attests that she/he meets the following requirements:

  1. Holds a current license as a MFT, LCSW, Licensed Psychologist, Board Certified Psychiatrist
  2. Possess at least two (2) years experience since licensure;
  3. Is employed by this agency or has a written Volunteer Supervision Agreement;
  4. Has training as a supervisor as required by state law pertaining to his/her licensure (6 hours of CEUs required for MFTs).

Should the Primary Supervisor no longer provide this student with supervisory services, the studentmust immediately notify the student’s fieldwork university instructor in writing and provide a new MFT Trainee Fieldwork Agreement (Form 6) and Form 6A with the name of the newly qualified primary supervisor with credentialing information.

Additionally, the practicum site attests that it:

  • Has a general signed Fieldwork Agreement on file with the Department of Educational Psychology and Counseling at CSUN (available at on the fieldwork page).
  • Has been in operation at least one(1) year.
  • Provide adequate facilities and equipment for the student to carry out designated responsibilites.
  • Have and adhere to published procedures for 1) handling grievances; 2) prohibiting discrimination on the basis of age, culture, ethnicity, gender, phyiscal disability, race, religion, sexual orientation, and socioeconomic status; 3) informed consent of clients, including but not limited to client rights, limits of confidentiallity, and establishmet and collection of fees; and 4) safety, privacy and confidentiality.
  • Allow for videotaping of client sessions, to be shared with site supervisor and university supervisor. Students will be responsible for locking and securing recordings at all times, including during transport. Students are expected to bring 2 recordings per semester to campus.If a site refuses to allow for videotaping to be securely transported to campus, the student will need to secure a second site that does allow for this.
  • Provide appropriate orientation to the policies and procedure of the internship site.
  • Be chartered or licensed by the appropriate state authority (as applicable).
  • If over 50% of student’s therapy is conducted in another language, the individual supervisor must speak that language or the student must have regular access to consult with a supervisor who does speak the language. Also, some of the student’s case load should be with English speaking clients to provide experience in both languages.
  • Provide sufficient client case load to meet requirements outlined in the CSUN Field Placement Agreement.
  • Students or supervisors will not be moved to other sites under an umbrella organization unless those sites have been approved by CSUN including the permission of the FieldworkCoordinator.

Primary Supervisor Responsiblities

  • Online Evaluation of Student: Each semester, the supervisor will complete an online evaluation of the student. The student will request the supervisor’s email at the beginning of the semester. The supervisor will be sent two emails, one with a password and one with a link, towards the end of the semester. The supervisor is required to meet individually with the student to review the evaluation. The evaluation is due to the universityin the last week of classes each semester; it is the student’s responsibility to inform the supervisor of this due date. The online evaluation is considered complete, only when the supervisor selects the “submit” button at the end of the evaluation. The supervisor will know the evaluation has been received when he/she receives an email copy of the evaluation. Supervisors must be willing to complete this online evaluation to supervise a student at CSUN.
  • Sign BBS Supervisor Responsibility form during first week of supervision.
  • Sign two sets of hour logs each week: one for the BBS and one for the university.
  • Meet with student weekly for individual and/or group supervision, which should live data on a regular basis.
  • Arrange for coverage in weeks when supervisor is out of town and/or ill.
  • Arrange for emergency consultation when students have questions about legal and ethical issues.
  • Provide oversight of clinical paperwork.
  • During supervision meetings, supervisors should regularly discuss how theories are being applied in cases students are working with.

PRIMARY ACTIVITIES

Place(s) where student will be providing services:

Trainee will provide services for:

Individual Adults

Children/Adolescents

Couples and Families

Groups

The student will provide hours of direct client service each week during the following days/times: .

Supervision:

The site will provide

Individual supervision

Group supervision

Co-therapy training (with more experienced intern or licensed professional)

Live supervision (either observation or video supervision)

Supervision by an AAMFT Approved Supervisor (advantageous for students moving out of state or pursuing doctoral programs)

Weekly supervision is scheduled on the following day(s)/time(s): .

Note:5 total hours of co-therapy training, taped, or live supervision (or combination) is required per semester.

Trainee will gain experience in (checked boxes are required by BBS):

Assessment/Diagnosis: Describe:

Psychotherapy: Describe:

Treatment Planning/Case Documentation: Describe:

Case Management/Advocacy: Describe:

Diverse Client Population: Describe:

Crisis Management: Describe:

Other: Describe:

Trainees have the opportunity to participate in:

Training seminars at site: Training will include topics such as:

Staff meetings: Date/Time:

Continuing education seminars or conferences off site.

The student is expected to attend the following trainings during the following dates and times:

Total Number of Hours

Student is expected to provide a total of hours of direct client service per week and spend a total of hours per week at the site to include supervision, training, and paperwork.

Student will begin training on and end on .

This agreement is null and void in the event the student has not received adequate supervision and training in compliance with the above standards and/or the parties have failed to comply with the CSUN clinical training manual for marriage and family therapy.

Procedure for Addressing Student/Supervisor Concerns

The procedure for handling conflicts between the student and agency or supervisor is for the student to address these difficulties with his/her primary supervisor at the Agency, or if the supervisor has concerns to address these directly with the student as early as possible. If the problem is not resolved, the student and/or supervisor should address their concerns with the student’s Fieldwork Instructor and/or the Fieldwork Coordinator. If necessary, a written addendum to the
this Trainee Fieldwork Agreement may be used to address concerns. Additionally, in coordination with the fieldsite, the Fieldwork Instructor may refer the student the Department’s Student Affairs Committee to address more serious concerns related to academic, competency, and/or legal/ethical issues.

INDEMNIFICATION

The above-named Agency hereby assumes all risk and liability for, and hereby indemnifies, protects and saves harmless, and hereby releases CSUN and each and every one of its officers, agents, faculty and employees of, from and against all liability, losses, injuries, damages, claims, suits, fees, including attorney's fees, costs or judgements which may arise from the student's performance of services while at the Agency. The assumption of risk, liability and indemnification under this paragraph shall survive the termination of this agreement. This agreement supersedes all agreements, understandings and communications between CSUN, the above named agency and student. This agreement may be modified or amended in writing.

The undersigned have read and agreed to the terms and conditions set forth in this agreement.

TERMINATION

This Agreement may be terminated by either party giving forty-five (45) days written notice of intent to terminate the Agreement. Exceptions can be made to this in the event of serious legal or ethical breaches and/or harm to clients. If the Trainee is initiating the termination, sufficient time must be provided to the site to transfer or terminate clients. In the event the practicum site is terminating the Agreement, the site shall initiate a good faith effort to accommodate the completion of the current rotation experience.

SITE DIRECTOR/ADMINISTRATOR

______

NAME (please print or type)TITLE

______

SIGNATURE DATE

PRIMARY SUPERVISOR

______

NAME (please print or type) TITLE

______

SIGNATUREDATE

STUDENT

______

SIGNATURE DATE

CSUN: FieldworkInstructor or Cooridinator

______

SIGNATURE DATE

Revised Jan. 2016