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Agency Application for Practicum Placement

Contact:

MSW Practicum Coordinator - Michelle Guarino
BSW Practicum Coordinator - Crystal Campbell

Agency Name

Program

Contact Person

MSW Supervisor

Address

Phone

- -

First 3 digits of phone number (area code) Next 3 digits of phone number Last 4 digits of phone number

Fax

- -

First 3 digits of fax number (area code) Next 3 digits of fax number Last 4 digits of fax number

Email

URL

Level

BSW Program MSW Foundation Yr MSW Advanced Yr

Agency Auspices

Select an option Public Private, Non-Profit Private, For Profit

Age Groups of Population Served

Infant Pre-School Elementary Adolescent Young Adult Adult Older Adult

Setting

Select an option Direct practice (micro) Indirect practice (macro) Micro/macro combination

Transportation

Select an option Car Needed Car Not Needed

Typical Work Hours:

Can your Program accommodate students with disabilities?

Select an option Yes No

Number of Students Program Can Accommodate

Pre-Placement Screening Required (Select all that apply using CTRL)

Drug screen Criminal Check Physical Exam TB Test Other

If other was selected, enter additional pre-placement screening

Fields of Practice (Select all that apply using CTRL)

Adoptions Adult Day Program Advocacy Aging AIDS/HIV At-Risk Youth Child Welfare Community Health Community Organizing Criminal Justice Developmental Disab. Employee Assit Prog. Employment Families Foster Care Group Homes Health Homeless/Housing Juvenile Delinquency Legal Services Long-Term Care Mental Health/Illness Physically Challenged Pregnancy, High Risk Pregnancy, Teen Public Policy Protect Serv, Adult Protect Serv, Child Rehabilitation Residential Care Schools Skilled Nursing Facility Social Service Agency Social Justice Substance Abuse Women Other(describe)

If other was selected, enter additional fields of practice

Major Functions students will be expected to perform (Select all that apply using CTRL)

Administration Advocacy After Care/Follow Up Assessment Case Management Client Empowerment Community Education Community Organizing Community Outreach Counseling Consultation Crisis Intervention Data Collection Discharge Planning Documentation Evaluation/Research Family Services Fundraising Grant Writing Group Work, Large Group Work, Small Health Education Home Visits Individual Counseling In-Home Services Information/referral Intake Legal Services Legislative Activities Mentoring Multidisciplinary work Networking Planning & Budgeting Policy Analysis Prevention/Education Program Evaluation Public Speaking Referrals Social Action Social History Team Meetings Treatment planning Other(describe)

If other was selected, enter additional functions

Describe the tasks/assignment for an intern in your agency?

Briefly describe the ideal student for a placement at your agency.

Do you offer pay/stipend for social work intern?

 Yes    No

Is this an entirely new placement?

 Yes    No

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