School Psychology Program, PRACTICUM

Practicum Agreement

Name of School

School Address, City, State, Zip

School Telephone Number

agrees to accept as a practicum student

Name of Student

and who is being mentored by

Name of Supervising Practitioner Enter the last four digits your SSN

(If you are mentoring a student for the first time, please complete an IRS Form W-9.)

Home Address, City, State, Zip

Telephone and E-mail Address

The school district and practicum student agree to observe the following arrangements in meeting the requirements of the practicum.

  1. DURATION: The practicum will begin in early September and continue through the end of the school year. Students are expected to follow the public school’s calendar with the exception of a one week vacation at the Tufts spring break.
  1. HOURS: The practicum student is available on Monday, Wednesday and Friday and is expected to work approximately 20 hours per week. Over the year the practicum student must accumulate at least 600 hours of supervised experience.
  1. SUPERVISION: The practicum student will receive at least one hour of direct supervision per week.
  1. SEMINARS AND IN-SERVICE TRAINING: The practicum student is expected to attend the following seminars and/or in-service training program(s):
  1. RECORD KEEPING: The practicum student is expected to maintain up-to-date records as follows:
  1. UNIVERSITY CONTACTS: The program seeks to facilitate regular communication with field sites through a series of ongoing contacts as follows:

a.  The University Supervisor will telephone the Supervising Practitioner early in the year to introduce him/her self and discuss the beginning of the year.

b.  The University Supervisor will visit the field site on three occasions as described in the Guidelines for Practicum Field Placements. Please see the Pre-Service Performance Assessment for Practicum for documentation of site visits.

  1. OTHER REQUIREMENTS: The practicum student will participate in other practicum related activities as follows:
  1. SUPERVISING PRACTITIONER: For all that apply; please enter your license number(s) below.

a.  State Department of Education License Number:

b.  Nationally Certified School Psychologist:

c.  Licensed Educational Psychologist (Board of Registration):

d.  Licensed Psychologist (Board of Registration):

  1. TRAINING COMMITMENT: The local school system is committed to the practicum as primarily a training experience. Employing practicum students as a means of providing services is unacceptable. Practicum students are expected to participate in tasks appropriate to the completion of the professional learning plan and to the domains of practice defined by NASP. The practicum student will not be asked to serve in any capacity other than that for which she or he was appointed.
  1. DUTIES: The practicum student is expected to spend most of his/her time practicing the roles and functions of a school psychologist. This role should include provision of direct services in assessment, intervention, and consultation as appropriate to the student’s ability. Students should only be performing duties of the school psychologist and not be asked to perform other functions. Specifically, the student’s duties will include:

Student Name Date

Supervising Practitioner Name Date

University Supervisor Signature Date

NOTE: Supervisory evaluations must be written by the last class meeting of each semester. We must have your evaluation by this time in order to assign grades by the University deadline.

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