SCHOOL OF SOCIAL WORK - AGENCY FIELD PRACTICUM APPLICATION

SCHOOL OF SOCIAL WORK MISSION STATEMENT

The Mission of the School of Social Work is to educate students to practice social work competently with the diverse, multicultural populations of New Mexico and the Southwest. The School has a primary commitment to Hispanic and Native American people. Our curriculum grounds students in core professional social work values, skills and ethical principles, with a focus on promoting awareness and respect for cultural and gender differences and how poverty affects the well being of people in the region.

AGENCY DEMOGRAPHIC SECTION

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AgencyName-Division/Department (if applicable) Director/Program Administrator

______
Mailing Address City State Zip
______
Agency Phone Number Fax Number E-mail Address
______
Website Address (if applicable)
1.Type of Agency.

[ ] Governmental (federal, state, county, city)

[ ] Private non-profit

[ ] Private for profit

[ ] Other, specify ______

  1. What type of client fee schedule does your agencyuse? Check all that apply.

[ ] No fees

[ ] Sliding fee scale

[ ] Set fees

[ ] Third party payments

[ ] Other, specify ______

  1. What percentage of your agencybudget is from the following sources?

Medicaid______%

Medicare______%

Client Fees______%

Indian Health Service______%

Contract (State, Federal)______%

Other, specify______%

  1. Provide a demographic profile of your current agencypersonnel.

NUMBER OF STAFF BY DISCIPLINE
/ OTHER DISCIPLINES
BSW / MSW / MD / Ph.D. / R.N.
African American
Asian American
Hispanic
Native American
White Caucasian
Other (specify)
Total

5. Provide a demographic profile of the approximate number of clients/consumers served by your agency within the currentyear.

NUMBER OF CLIENTS/CONSUMERS SERVED BY GENDER

Male

/

Female

African American

Asian American

Hispanic
Native American
White/ Caucasian
Other
Total

6. Dothe client/consumerdemographics reflect the population that field practicum students will be working with?

______Yes ______No (If no, please explain)

______

______

7. What client/consumer age groups are served by your agency? (Check all that apply)

[ ] Children 0 – 3 years

[ ] Children 4 – 5 years

[ ] Children 6 – 10 years

[ ] Children 11 – 13 years

[ ] Adolescents 14 – 17 years

[ ] Adults 18 – 35 years

[ ] Adults 36 – 65 years

[ ] Adults 66 years & older

8. Which of the following best describe the services your agencyprovides? (Check all that apply)

[ ] Intakes/Assessments

[ ] Case Management

[ ] Administration/Program Planning

[ ] Research/Program Evaluation

[ ] Therapy/Counseling

[ ] Community Organization (advocacy, networking, lobbying, etc).

[ ] Educational/Oral Presentations

[ ] Other: (please specify) ______

  1. Why is your agency interested in becoming a practicum site?
  1. How many years has your agency been in operation?
  1. How many program locations does your agency have and in which communities?
  1. Describe how your agency will provide learning opportunities that will enhance and promote the Schools’

Mission and thelearning expectations of our students.

  1. Please indicate how the practicum will be structured and designed at your agency and the kinds of activities and projects the students will be assigned.
  1. How is your agency/site promoting or addressing cultural awareness/competence and incorporating the

following CulturalCompetency Standards? Please elaborate.

  1. Socio-Cultural Factors in Health Care Delivery
  1. Population Health Disparities
  1. Intercultural communication
  1. New Mexico Historical Trauma (if agency is NM based)
  1. How many students (by classification) is your agency capable of accepting for practicum placement?

______BSW

______MSW 1st year

______MSW 2nd year - Indicate below how many 2nd year students your agency can accept within each of the concentrations.

_____ Clinical Practice _____ Government Non Profit _____ Bilingual/Bicultural Clinical Practice

Management

  1. Does your agency have a particular theoretical practice orientation (i.e., Behavioral, Psychodynamic)?
  1. Is your agency’s Board of Directors/ Chief Administrative Office committed to the agency functioning as a field practicum site for social work students and allowing agency instructors time to carry out the supervising responsibilities asset forth by the School of Social Work? ______Yes ______No
  1. Will student be expected to travel? ______Yes ______No
  1. If yes, will agency reimburse the student for travel? ______Yes ______No

(The School of Social Work prohibits students from transporting clients. Refer to field manual for details.)

  1. Will your agency be able to provide the student with workspace, materials, supplies and phone access

needed tocomplete practicum responsibilities? ______Yes ______No

  1. Do you have any special requirements of student (i.e., language proficiency, drivers license, special hours, attendance at specific meetings/ trainings, continuing client visits during school breaks)? Please describe.
  1. Can the agency provide financial support for the student(s) practicum? ______Yes ______No
  1. If yes, please indicate the type and amount of financial support your agency can provide.

______

  1. Will the student have the opportunity to directly observe the agency instructor carrying out his/her

professional role (i.e., observing agency instructor working with clients)? ______Yes ______No

If no, please explain.

  1. If your agency does not have MSW personnel to supervise, can arrangements be made to have MSW

supervision? ______Yes ______No

______

Print Name and title of person completing form Signature Date

Depending on the location,of your agency submit Agency Application, Memorandum of Agreement, and

Agency Instructor Application to relevant program location:

NMHU-School of Social Work(Attention: Field Director),

Box 9000 Las Vegas, NM 87701

(505) 454-3326/ 454-3294. FAX: (505) 454-3290

NMHU School of Social Work @ Albuquerque(Attention: Field Coordinator),

5041 Indian School Rd NE Suite 100, Albuquerque, NM 87110

(505) 260-6190/260-6182 FAX: (505) 896-6122

NMHU School of Social Work In Partnership with San Juan College(Attention: Field Coordinator),

3539 E. 30th Street #203 Farmington, NM 87402

(505) 566-3552, FAX: (505) 566-3584

NMHU School of Social Work In Partnership with ENMU-R(Attention: Field Coordinator),

P. O. Box 6000, Roswell, NM 88202

(575) 624-7458, FAX: (575) 624-7457

Enclose pamphlets, brochures, and literature that describe your agency and services

Online Document Link 1129 Rev 11/1/12