School Psychology Program, PRE-PRACTICUM
Pre-Practicum Agreement
Return by October 15
Name of School
School Address, City, State, Zip
School Telephone Number
agrees to accept as a pre-practicum student
Name of Student
and who is being mentored by
xxx-xx-
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 pre-practicum student agree to observe the following arrangements in meeting the requirements of the pre-practicum.
1. DURATION: The pre-practicum will begin in September or early October 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.
2. HOURS: The pre-practicum student is available on Monday, Wednesday or Friday as arranged between the student and the Supervising Practitioner. The student is expected to work approximately 6 hours per week. Over the year the pre-practicum student should accumulate at least 150 hours of supervised experience.
3. SUPERVISING PRACTITIONER: For all that apply; please enter your license number(s) below.
State Department of Education License Number:
Nationally Certified School Psychologist:
Licensed Educational Psychologist (Board of Registration):
Licensed Psychologist (Board of Registration):
Supervising Practitioner written evaluations are due by January 15th for the fall semester, and by June 1st for the spring semester.
4. UNIVERSITY CONTACTS: The program seeks to facilitate regular communication with field sites through a series of ongoing contacts as follows:
a) The field placement coordinator will contact the Supervising Practitioner to arrange the placement and plan for the beginning of the year.
b) The program will provide the Supervising Practitioner with relevant course syllabi and a timetable of assignments for pre-practicum students for each semester as needed. All pre-practicum students will participate in a weekly one hour pre-practicum seminar at the university.
c) One site visit will be made during the pre-practicum year.
5. DUTIES: Pre-practicum students will be expected to spend their time observing, learning, and beginning to function in the various roles of a school psychologist (i.e. assessment, TEAM meetings, individual and/or group counseling, consultation, parent meetings, etc.). Students should only be performing duties of the school psychologist and not be asked to perform other functions. Based on student progress, the student’s duties are likely to include:
Student Name Date
Supervising Practitioner Name Date
University Supervisor Signature Date
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