Department of Counseling &

Educational Psychology

PRACTICUM (CEP CLINIC) SUPERVISORY AGREEMENT FORM

BECAUSE THE CEP CLINIC IS A SITE INTERNAL TO THE COUNSELING AND EDUCATIONAL PSYCHOLOGY DEPARTMENT, NO FURTHER MEMORANDUM OF UNDERSTANDING OR AGREEMENT IS REQUIRED.

The purpose of this agreement is to ensure an understanding of the responsibilities of all parties involved in MA-CMHC Counseling Practicum experiences at the CEP department training clinic. Clinical training experiences provide hands-on opportunities for students to apply their knowledge and skills and become familiar with the counseling profession. Clinical supervision is a key component of clinical training experiences. Supervision facilitates students’ understanding of the counseling process, provides opportunities to further develop skills, and assists with students’ professional accountability. Supervisors that agree to provide supervision mustreview and sign this supervisory agreement, return the original to the student, and retain a copy. Please note that students are responsible for completing the number of clinical hours required for practicum. They must do so within the timeframe specified on this form. Extension of this timeframe may be considered by the instructor and training site on a case-by-case basis.

CEP 572 COUNSELING PRACTICUM
INSTRUCTOR: SEMESTER:
CONTACT PHONE # EMAIL ADDRESS:
CREDIT HOURS: NUMBER OF CLINICAL HOURS TO COMPLETE:
PRACTICUM START DATE: END DATE:
PRACTICUM STUDENT
NAME: BANNER ID #
ADDRESS:
CELL PHONE #: EMAIL ADDRESS:
CEP TRAINING AND RESEARCH CLINIC
DOCTORAL STUDENT SUPERVISOR
NAME: TITLE:
LICENSE: DEGREE: YEARS OF EXPERIENCE:
CONTACT PHONE #: EMAIL ADDRESS:
FACULTY SUPERVISOR OF DOCTORAL STUDENT SUPERVISOR
NAME: PROGRAM:
PHONE #: EMAIL ADDRESS:
MA-CMHC PRACTICUM INSTRUCTOR
The practicum instructor/faculty supervisor agrees to (please initial here) ______:
  1. Provide face-to-face group supervision for a minimum of 1.5 hours per week in which time students present cases for input and assistance. To provide training on various topics, an additional 0.5 hours may be added to the class schedule each week
  2. Inform students of their responsibility to abide by all administrative policies, rules, standards, schedules, and practices of the class and the clinical site;
  3. Facilitate communication between the program and the clinic, attend program committee meetings, and meet regularly (e.g., bi-monthly) with site supervisors to discuss student progress/growth edges;
  4. Provide clinical supervision, including by reviewing video or audio tapes (andthrough live supervision if desired), retain ultimate authority for the direction of clinical work, provide evaluative feedback to students, and assign a course grade;
  5. Be available for consultation with student outside of class hours, including should any problem or change occur in relation to clients, the student, site, or program.
CEP TRAINING CLINIC SUPERVISOR UNDER SUPERVISION
The doctoral student supervisormeets the following requirements (please initial here)______:
  • Has a minimum of a master’s degree in counseling or a related profession, with training similar to training provided in a CACREP-accredited masters program
  • Has completed a total of 600 direct hours of supervised clinical work, either in master’s or doctoral training or in paid clinical work
  • Is taking or has taken a supervision course as part of their training and is under the supervision of an advanced supervisor, who provides input into supervision processes
  • Has the time and interest in training master’s level clinicians and is knowledgeable about the clinical mental health counseling profession
Thesite supervisor agrees to(please initial here) ______:
  1. Provide the student with adequate work space, telephone, office supplies, and staff to conduct professional activities, and orient practicum students to clinic procedures
  2. Provide face-to-face individual or triadic supervision for a minimum of 1 hour per week
  3. Be available in the clinic while practicum students are meeting with clients, at least initially, and be reachable whenever practicum students are meeting with clients
  4. Review and provide supervisory feedback onvideo tapes, observation, and/or joint sessions for a minimum of 1 hour per week
  5. Provide opportunities for the student to engage in a variety of counseling activities under supervision, including for the purpose of adequately evaluating the student’s performance
  6. Provide a written evaluation of student, based on the criteria established by the MA-CMHC program
  7. Be available to meet with the faculty supervisor on a bi-weekly basis and for consultation with the practicum student and/or faculty supervisor as needed

Revised 04/05/18 1

MA-CMHC PRACTICUM STUDENT
The MA-CMHC practicum student agrees to (please initial here) ______:
  1. Secure professional liability insurance coverage and provide a copy to the faculty supervisor before beginning any work in the clinic;
  2. Prior to initiating this agreement, notify the NMSU Office of Institutional Equity/EEO of any anticipated accommodations that may be necessary due to a disability, see
  3. Adhere to the administrative policies, rules, standards, and practices of the site;
  4. Act in a professional manner with clients, supervisors, staff members, and students;
  5. Keep both site and faculty supervisors informed of their clinical training experiences, including immediate notice of emergencies or ethical issues that arise as well as by sharing video tapes, etc.;
  6. Practice in accordance with the American Counseling Association ethical standards. Any breach of these standards or other unethical behavior will result in the student’s removal from the clinical training site, a failing grade in practicum, and documentation in the student’s permanent record;
  7. Demonstrate appropriate levels of counseling skill, knowledge, and competence;
  8. Complete all requirements for the practicum course.

Equal Opportunity – It is mutually agreed that no party shall discriminate on the basis of race, color, nationality, ethnicity, age, sex, or creed.
Termination – It is understood and agreed by and between the parties involved that the Agency/ Institution/School has the right to terminate this agreement. If, in the opinion of the site supervisor, a student’s behavior is detrimental to the operation of the Agency/Institution/School and/or to client care, the student may be terminated. Such action will not be taken until the grievance against the student has been discussed with the student and with University Officials.
Please initial the appropriate section(s) above and sign below:
MA-CMHC Supervisor:______Date:______
Clinic Supervisor:______Date:______
Student:______Date:______
All three parties should retaincopies of the finaland completed document

Revised 04/05/18 1