Internship Manual - Wayne State College

Wayne State CollegeMasters in Counseling Internship AgreementIntern name _________________________________________________________Home address _______________________________________________________Telephone __________________________________________________________E-mail _____________________________________________________________Work address _______________________________________________________Telephone __________________________________________________________E-mail _____________________________________________________________Internship Site address (if different) _______________________________________Telephone ___________________________________________________________E-mail ______________________________________________________________Supervisor’s Name, Degree/License ________________________________________Work Address _________________________________________________________Telephone ____________________________________________________________E-mail ________________________________________________________________Beginning Date of Internship _________________ Ending Date ______________Weekly Schedule – Internship hours and one hour minimum supervision timeMonday Tuesday Wednesday Thursday Friday SaturdaySignatures below indicate:The intern agrees to perform ethically and to communicate with all parties.The field supervisor agrees to provide a minimum of one hour per week of supervision, tocomplete midterm and final evaluations, and to communicate with the WSC supervisor.The administrator approves the internship at this site, approves occasional use of recordingof counseling sessions with appropriate consent forms to be viewed by the WSC supervisor,and informs the intern about site policies.The WSC supervisor approves the field site and supervisor, is available for consultationwith the field supervisor as needed, and provides small group supervision for interns._________________________________Intern Signature & Date_______________________________Field Supervisor Signature & Date________________________________Field Site Administrator Signature & Date_____________________________College Supervisor Signature & Date