Southern Arkansas University
Graduate Counseling Program
Practicum Supervision Agreement
1.Student Information
Name: ______________________________________________ Phone: _______________
Address: __________________________________________________________________
SAU E-mail:________________________________________________________________
2. Site Information
Name: ______________________________________________ Phone: _______________
Address: __________________________________________________________________
_________________________________________________________________________
Types of clients served: _______________________________________________________
3. Length of agreement
Practicum Duration:
Beginning date __________ Ending date ____________
Hours per week: _________ Days of Week: __________________________
_______ (student initials) I have verified with my site supervisor that I am agreeing to complete
my practicum in the time-frame provided.
4. Site Supervisor Information
Name: _________________________________________ Title: _______________________
E-mail:____________________________________________ Phone: __________________
Licensure/Certifications Attained
___ LPC ___NCC ___ Licensed School Counselor ___NCSC
___ Other___________________________________(year attained______)
State where licensure/certification is granted _____________________
Degrees Held (Master's in Counseling or related field required) (Please list degrees and
conferring university)
___________________________________________________________________________
___________________________________________________________________________
Employment history (please give last 2 employers)
___________________________________________________________________________
___________________________________________________________________________
Experience providing counselor supervision and/or training for providing supervision
___________________________________________________________________________
___________________________________________________________________________
5. Practicum Taping Requirements
Students are required to record (videotaping is preferred) some of their sessions with the client's
permission obtained through a signed consent form. Students are required to submit a
minimum of three recordings during the semester for review with their university supervisor.
6. Responsibilities of University Supervisor, Site Supervisor and Practicum Student
Southern Arkansas University (SAU) Supervisor Responsibilities:
Conduct weekly group and/or individual supervision conferences with the student on the
SAU campus. Each student will receive at least one hour per week of supervision.
Provide additional individual supervision as requested or as needed for remediation.
Provide the site supervisor with current information on: a) dates of practicum
assignments, b) evaluations of practicum student, and c) practicum placement program
requirements.
Provide, as needed, group meetings for site supervisors to promote understanding and
improvement of the practicum placement program and supervision of practicum
students.
Complete two formal evaluations of the student (mid-semester and end of semester).
Evaluate counseling skills and assign grade to the student.
Is available to the student and site supervisor in the event of any emergency client
situation.
Site Supervisor Responsibilities:
At a minimum: a) possess a master’s degree or higher in a human services field, b)
possess appropriate certification or licensure, c) have a minimum of two years pertinent
professional experience, d) be aware of the practicum placement program’s
requirements, and e) be approved by the university supervisor.
Provide a minimum of one (1) hour of weekly individual supervision in a confidential
area.
Attend at least one Site Supervisor Orientation a year at Southern Arkansas University;
understand student requirements & responsibilities.
Assist the student with the planning of the practicum experience.
Meet with University Supervisor once per semester. Maintain contact with the student's
university supervisor to express any concerns that may arise.
Provides the practicum student with site policies, rules, and regulations pertinent to the
student’s role in the placement site. Particular emphasis will be placed on requirements
for safeguarding client rights and confidential professional information.
Provide the student with supervised opportunities to counsel students, participate in the
planning and implementation of agency activities, and meet with other staff members.
Evaluate the student during the middle and end of practicum semester.
Practicum Student's Responsibilities:
Secure an approved site.
Obtain and maintain appropriate personal/professional liability insurance.
Adhere to the policies and procedures of the site.
Represent themselves and the university in a professional manner.
Follow the American Counseling Association’s Ethical Guidelines.
Complete self-evaluations for counseling skills and review of recorded sessions.
Evaluate the site and site supervisor (end of each semester).
7. Signatures
SAU Supervisor __________________________________ Date _________
Site Supervisor ___________________________________ Date__________
Student _________________________________________ Date__________