FIELD PLACEMENT APPLICATION
School Counseling Date
Name of School:
Phone Number:FAX Number:
Location:
Number and Street City, StZip
Additional Location:
Number and Street City, StZip
Mailing Address:
Number and Street City, StZip
Trainee Coordinator:
Phone Number: E-Mail:
San Francisco State University, Department of Counseling is committed to equal access for all students. Placement sites must be willing to accommodate students with disabilities, if students can perform the essential functions of the job, and if accommodations requested are reasonable.
Is this school willing to accommodate students with disabilities? Yes No
Is this school wheelchair accessible?Yes No
Description of Counseling Services provided & population served:
Counseling Services:Individual Yes No Group Yes No
Family Yes No Workshops Yes No
Age Range of Students: 0-5 6-10 10-13 13-18
Ethnicity of Student Population: Please describe using approximate %.
Supervision: Supervisors must have a valid PPS Credential
Degree (M.A., Ph.D.), Credential held by supervisor/s:
Supervision: - Individual - 1 Hour/Week Required No. of Hours Provided Each Week:
- Group: No. of Hours Provided Each Week:
Methods of Supervision: Case Presentation One-Way Mirror Video Taping
Audio Taping Process/Progress Notes Role Play
Tape recordings of trainee interviews with clients are required by this Department.
Students will be required to play tapes to faculty supervisors.
Is taping of interviews allowed by your school with permission from clients? Yes No
Responsibilities of Trainee: Please describe the fieldwork experience and responsibilities the trainee will have at your school. Please attach a copy of description of trainee duties provided to trainees.
Number of client hours per week the trainees are assigned: (A min of 2 and max of 8 hours are required for 1st yr. trainees and a minimum of 5 and maximum of 12 for 2nd yr. trainees.)
Do you have a didactic training component as a part of your program? Yes No
Please describe:
EMPLOYMENT STATUS OF TRAINEE:
- Volunteer
- W-2 EmployeeRate of Pay $
- StipendAmount $
Number of Hours Per Week Required of Trainee:______
Period of Traineeship: From ______To ______
What is your Trainee application process?
Mandatory Time Commitments: (please include as much information as possible, including day, week and time of staff meetings, trainings, etc., if applicable.)
The program is committed to a culture that is inclusive of, but not limited to, ethnicity, race, gender, sexual identity sexual orientation, religion, socioeconomic status, national origin, disability, age, and indigenous status. Therefore, we encourage supervisors from all cultural backgrounds to work with our diverse students.
Attach extra pages with your comments or additional information.
Field Placement Application-School
Revised: