University of HoustonGraduate College of Social Work

Office of Field Education(713) 743-8088 (713) 743-8014 FAX

AGENCY DESCRIPTION FORM

Agency Name:

Agency Phone:

Mailing Address:

Physical Address:

Agency Point of Contact: Email:

  1. Check what level of field experience is available for the students atthe agency:

Generalist Practice (First Year Students)

Advanced Practice (Concentration Year Students)

Clinical Practice Macro Practice

Either Generalist or Advanced Practice

Clinical Practice Macro Practice

  1. When can students complete the majority of their practicum hours? (Check onlyONE box)

Business Hours Evening and Weekend Hours Both

  1. Does the agency provide a student stipend?

Yes No

  1. Is free parking available to students?

Yes No

  1. Indicate the PRIMARY focus of the agency(Check onlyONE box)

GLBT Community Policy Immigration

HIV/AIDS Administration Spanish-speaking populations

Children Schools (K-12/College) Advocacy

Adolescents Health Pregnancy

Women Mental Health Child Welfare

Aging Communities Adoption/Foster Care

Families Recovery Domestic Violence

Homeless/Housing Poverty Sexual/Physical Abuse

Substance Use Ethnic Diverse Population Grief and Loss

Corrections/Juvenile Justice Developmental Disabilities Death/Dying

Other

  1. Indicate the SECONDARY Focus of the Agency (Check ALL that apply)

GLBT Community Policy Immigration

HIV/AIDS Administration Spanish-speaking populations

Children Schools (K-12/College) Advocacy

Adolescents Health Pregnancy

Women Mental Health Child Welfare

Aging Communities Adoption/Foster Care

Families Recovery Domestic Violence

Homeless/Housing Poverty Sexual/Physical Abuse

Substance Use Ethnic Diverse Population Grief and Loss

Corrections/Juvenile Justice Developmental Disabilities Death/Dying

Other

  1. Which geographical area best describes agency’s location?

South Houston Clear Lake/Pasadena

Southeast Houston Sugarland/Richmond

East Houston Kingwood/Humble

Northeast Houston Woodlands/Conroe

North Houston Katy

NorthwestHouston Galveston

West Houston Austin

SouthwestHouston Beaumont

Insidethe Loop Outof State

Downtown Other, please specify

Medical Center

  1. Give a brief description of the agency (Students will access to this information)
  1. Describe opportunities available for students at the agency(Students will have access to this information):
  2. Explain any required on-boarding procedures for the student (i.e. Background Check, Drug Screens, etc.):

Printed Name of Person Completing This Form

Telephone NumberWhere We May Reach you

Date

Revised: August 2016