Fieldwork Matching Form
Fall 2018 - Spring 2019
Applicant Information
Name: / Date: / Desired Fieldwork Term: / -Phone number: / Email address:
Which program and program year (1st/2nd/3rd, etc): / MSW Intern , year _____
MFT Trainee, year _____
Other: __ / Hours of fieldwork needed per week (ex: 20 hours, 3 days, etc):
Fieldwork days (Mon Wed Fri, etc):
Please indicate the supervision requirements of your program (ex: only MSWs or those two years past licensure or with a PPSC). Please attach any relevant forms your school has provided, as we cannot guarantee supervisor credentials that are not requested in advance.
Any particular certificate or placement type (PPSC, IV-E, art therapy, etc)? Such placements are not guaranteed, but we will try to honor requests made during placement.
University & City: / Expected Graduation Date:
Seneca Family of Agencies Policies
Please initial each box below to indicate that you understand and intend to comply with each of the following Seneca policies for graduate level interns and trainees.Seneca asks that all graduate interns/trainees commit to their field placement for at least 9 to 10 months.
All staff and graduate level interns/trainees must complete a two week training (Monday through Friday 9:30am to 5:30pm) prior to placement in a program. Most interns/trainees complete this training during the summer prior to placement. If you anticipate scheduling conflicts please note them here:
To maintain a safe environment for staff, interns/ trainees, and clients all staff and interns/trainees are trained on a de-escalation model that may include restraint and seclusion.
Applicant Interests
Placement Setting (Check all that apply. Please note that not all of these settings may be available in your area.)Adoption and Permanency / School-based / Crisis Support
Mental Health / Community-Based / Macro-level
Which populations are you interested in working with? (Rank your choices: 1= 1st Choice)
___ Children & Families / ___ Elementary School / ___ Teens / ___ Youth on Probation
___ Infants and Preschool / ___ Adolescents / ___ Transitional Aged Youth / ___ Youth in Foster Care
Geographic location: In which locations are you interested in working? (Rank your choices: 1=1st Choice)
Northern California / Southern California / Central California / Washington State
___ Alameda County
___ Contra Costa County
___ Marin County
___ San Francisco County
___ Santa Clara County
___ Solano County
___ Sonoma County / ___ Anaheim Hills, CA
___ Los Angeles, CA
___ Redlands, CA
___ Ventura, CA / ___ Salinas, CA
___ San Luis Obispo, CA / ___ Seattle Area
___ Tacoma Area
___ Spokane Area
Do you have a car available? (Some sites are not accessible by public transport and we provide transportation for clients in most programs):
Yes I have a car, am insured and able to transport clients.
Yes I have a car, am insured but not able to transport clients.
No I do not have access to a car, but am willing to drive a vehicle if one is provided.
How did you hear about Seneca Family of Agencies?
Please expand on your personal and professional goals that you hope to achieve while interning or training at Seneca Family of Agencies:
Additional comments:
Thank you for your interest in Fieldwork at Seneca Family of Agencies
Please attach this form to your cover letter and resume when submitting your online application.Please note that it may take up to ten business days to hear back from us regarding the status of your application.
If you have any further questions please contact our Fieldwork Coordinator
at the Seneca Institute of Advanced Practice (510) 654-4004.