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:
- 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
- When can students complete the majority of their practicum hours? (Check onlyONE box)
Business Hours Evening and Weekend Hours Both
- Does the agency provide a student stipend?
Yes No
- Is free parking available to students?
Yes No
- 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
- 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
- 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
- Give a brief description of the agency (Students will access to this information)
- Describe opportunities available for students at the agency(Students will have access to this information):
- 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