<p> 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 </p><p>FIELD PLACEMENT APPLICATION</p><p>CRMH Counseling Date </p><p>Name of Placement: </p><p>Phone Number: FAX Number: </p><p>Location: Number and Street City, St Zip</p><p>Additional Location: Number and Street City, St Zip</p><p>Mailing Address: Number and Street City, St Zip</p><p>Trainee Coordinator: </p><p>Phone Number: E-Mail: </p><p>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.</p><p>Is this agency willing to accommodate students with disabilities? Yes  No  Is this agency wheelchair accessible? Yes  No </p><p>Description of Services provided & population served: </p><p>Counseling Services: Individual Yes  No  Group Yes  No  Family Yes  No  Workshops Yes  No  Age Range of Clients: 0-11  12-18  Adults  Seniors </p><p>Ethnicity of Client Population: Please describe using approximate %.</p><p>Type of Supervision: .</p><p>Attach extra pages with additional information or comments Field Placement Application: Degree (M.A., Ph.D.), Certification (e.g., CRC ) held by supervisor/s: </p><p>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</p><p>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</p><p>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.</p><p>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.)</p><p>Do you have a didactic training component as a part of your program?  Yes  No Please describe:</p><p>EMPLOYMENT STATUS OF TRAINEE:  - Volunteer  - W-2 Employee Rate of Pay $  - Stipend Amount $ </p><p>Number of Hours Per Week Required of Trainee:______</p><p>Period of Traineeship: From ______To ______</p><p>What is your Trainee application process? </p><p>Mandatory Time Commitments: (please include as much information as possible, including day, week and time of staff meetings, trainings, etc., if applicable.)</p><p>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.</p><p>.</p><p>Attach extra pages with additional information or comments Field Placement Application: </p>