Field Placement Application
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San Francisco State University College of Health & Social Sciences Department of Counseling 1600 Holloway Avenue, BH 524 (415) 338-2005 San Francisco, California 94132 (415) 338-0594 Fax
FIELD PLACEMENT APPLICATION
CRMH Counseling Date
Name of Placement:
Phone Number: FAX Number:
Location: Number and Street City, St Zip
Additional Location: Number and Street City, St Zip
Mailing Address: Number and Street City, St Zip
Trainee Coordinator:
Phone Number: E-Mail:
San Francisco State University, Department of Counseling is committed to equal access for all students. Placement sites must be willing to accommodate students with disabilities, if students can perform the essential functions of the job, and if accommodations requested are reasonable.
Is this agency willing to accommodate students with disabilities? Yes No Is this agency wheelchair accessible? Yes No
Description of Services provided & population served:
Counseling Services: Individual Yes No Group Yes No Family Yes No Workshops Yes No Age Range of Clients: 0-11 12-18 Adults Seniors
Ethnicity of Client Population: Please describe using approximate %.
Type of Supervision: .
Attach extra pages with additional information or comments Field Placement Application: Degree (M.A., Ph.D.), Certification (e.g., CRC ) held by supervisor/s:
Supervision: - Individual: 1 Hour/Week Required No. of Hours Provided: ____ - Group: No. of Hours Provided: Methods of Supervision: Case Presentation One-Way Mirror Video Taping Audio Recording Required Process/Progress Notes Role Play
Tape recordings of trainee interviews with clients are required by this Department. Students are required to play tapes to faculty supervisors. Is taping of interviews allowed by your agency with permission from clients? Yes No
Responsibilities of Trainee: Please describe the fieldwork experience and responsibilities the trainee will have at your agency. Please attach a copy of description of trainee duties provided to trainees. If duties will be performed off site please explain emergency contact procedures.
Number of client hours per week the trainees are assigned: __ (A minimum of 2 and maximum of 8 clients are required for 1st yr. trainees and a minimum of 5 and maximum of 12 clients for 2nd yr. trainees.)
Do you have a didactic training component as a part of your program? Yes No Please describe:
EMPLOYMENT STATUS OF TRAINEE: - Volunteer - W-2 Employee Rate of Pay $ - Stipend Amount $
Number of Hours Per Week Required of Trainee:______
Period of Traineeship: From ______To ______
What is your Trainee application process?
Mandatory Time Commitments: (please include as much information as possible, including day, week and time of staff meetings, trainings, etc., if applicable.)
The program is committed to a culture that is inclusive of, but not limited to, ethnicity, race, gender, sexual identity sexual orientation, religion, socioeconomic status, national origin, disability, age, and indigenous status. Therefore, we encourage supervisors from all cultural backgrounds to work with our diverse students.
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Attach extra pages with additional information or comments Field Placement Application: