UBC School Psychology Program Sample Practicum or Internship Agreement The following is a sample of a suggested format to follow when the Practicum Intern Coordinator the Practicum Student or Intern by set6tyhsd


									                        UBC School Psychology Program
                    Sample Practicum or Internship Agreement

 The following is a sample of a suggested format to follow when the Practicum/Intern
   Coordinator, the Practicum Student or Intern, and the Field Supervisor develop a
          Practicum Agreement. It may be adapted with approval of the UBC
      Practicum/Internship Coordinator depending on the needs of the practicum
                     student/intern, field supervisor, and/or setting.


Practicum Student/Intern:                           Phone:
Field Supervisor:                                   Phone:
Agency:                                             Email:

Address of practicum/internship site:

University Practicum/Internship Coordinator:
                                                    Phone:                         Email:
Dates of Practicum/Internship:

Mailing Address of Practicum/Internship Site:

Description of the Practicum (or Internship)
The Practicum Student/Intern will complete at least ### hours of supervised practicum from
DATE to DATE. The Practicum placement will be with the NAME OF AGENCY. NAME OF
AGENCY provides DESCRIBE THE AGENCY AND SERVICES . You should attach an agency
brochure, if one is available. The Practicum/Internship will allow for a experiences in a number
of psychological services including assessment, intervention and/or consultation at both the
individual and/or systems level. The Practicum/Internship will provide opportunities to work
with a diverse range of clients and to enhance professional skills in a community-based context.
WILL BE PROVIDED AT THIS SITE (e.g., This Practicum/Internship will provide specialized
training in providing psychological services to young children in the area of early childhood
mental health.) The nature of the Practicum/Internship activities and psychological services
provided are described below and detailed in the Practicum/Internship Plan. A team of
supervisors (detailed in the attached Practicum/Internship Plan document) will be responsible
for on-site supervision. The supervision team will be lead by NAME OF PRIMARY SUPERVISOR
(on-site) #### registered psychologists, LIST NAMES and ### other supervisors with relevant
content area and professional expertise LIST NAMES.

Objectives of the Practicum
As part of the Practicum/Internship experience and to the extent possible within the agency,
the Practicum Student/Intern will increase competency in the following areas: THE FOLLOWING
    • Knowledge of the organization and functioning of public schools, mental health centers,
        or other agencies
    • Familiarization with psychological service delivery procedures
    • Familiarization with the various roles and functions of professional psychologists, special
        and regular educators, school administrators, and other mental health providers
    • Refinement of communication and consultative skills and the ability to engage in team
    • Refinement of assessment and diagnostic skills
    • Refinement of direct intervention skills
    • Further development of research and evaluation skills
    • Effective utilization of community and institutional resources
    • Continued professional growth through in-service training, self-study, and supervisory
    • Continued development of an understanding of ethical and legal issues in psychology
        and education
Additional details of the goals, objectives, primary supervisor and method for evaluation is
provided in the Practicum/Internship Plan document which accompanies this agreement.
Terms of the Practicum/Internship Agreement
As a practicum student/intern from the School Psychology Program at the University of British
Columbia, PRACTICUM STUDENT NAME will complete a Practicum/Internship experience with
NAME OF SITE on the following terms:

       Total hours minimum per week on agency site: ##          OR
       Days per week on school district/agency site (specify days): ##

       For the period of the Practicum/Internship, the Practicum Student/Intern will carry the
       title of: ___PRACTICUM/INTERN STUDENT TITLE___________
       The Practicum Student/Intern works under the administrative control of _______NAME
       OF AGENCY
       The Practicum Student/Intern’s direct administrative supervisor is
       The Practicum Student/Intern is also under the academic control of the University of
       British Columbia, and the joint professional control of the Field Supervisor(s)
       ______________________NAME(S) and the University Practicum/Internship Coordinator

Practicum/Internship Activities
The Practicum Student/Intern will work on a full-time basis from DATE to DATE. The Practicum
Student/Intern will be involved [[in six primary activities (consultation, assessment,
intervention, report writing and related activities, supervision and training, and program
development activities) INDIVIDUALIZE THIS]]. The Practicum Student/Intern will keep an
Practicum/Internship Log in which daily activities, supervision experiences, and self-evaluations
are recorded. The log is useful during supervision, but must be available for review with the
University Practicum/Internship Coordinator throughout the Practicum/Internship.
The primary Practicum/Internship activities will include: THESE ARE EXAMPLES, INDIVIDUALIZE
   •   ##% consultation services
   •   ##% direct face-to-face client hours
   •   ##% report writing, case notes, assessments, paperwork
   •   ##% supervision
   •   ##% training activities
   •   ##% specialized emphasis

The Practicum Student/Inter ________NAME will assume major responsibility for preparation
and approval of the Practicum/Internship agreement and plan, and will fulfill the terms of the
Practicum/Internship plan as agreed to by all parties ____NAME_________, the Practicum
Student/Intern; ___NAME______________ as Primary Field Supervisor;
_____NAME________________ as Field Supervisors; and
_____NAME___________________University Practicum/Internship Coordinator).

The Field Supervisors will share responsibility for supervision and evaluation of the Practicum
Student/Intern and will ensure that the psychological services provided by the Practicum
Student/Intern meet high professional standards. The Field Supervisors will provide the
Practicum Student/Intern with a minimum of 2 hours per week of direct supervision of a
didactic nature (e.g., case conferences, seminars, in-service training) and at least 2 hours per
week of face-to- face feedback and interaction.

The Field Supervisors will provide two written evaluations of the Practicum Student/Intern’s
performance and these evaluations will be submitted to the Practicum Student/Intern and the
University Practicum/Internship Coordinator at both the midway point of the
Practicum/Internship and at the end of the Practicum/Internship.

The University Practicum/Internship Coordinator will work directly with the Field Supervisors
and the Practicum Student/Intern. The University Practicum/Intern Coordinator will be involved
in the formulation of the Practicum/Internship plan, in the negotiation of the supervisory
agreements, and in the evaluation of the Practicum student/Intern’s performance. The
University Practicum/Internship Coordinator will meet jointly with the Practicum/Internship
Student and the Field Supervisors prior to the beginning of the Practicum/Internship, as needed
throughout the Practicum/Internship, and at the conclusion of the Practicum/Internship. The
University Practicum/Internship Coordinator will also have regular (approximately twice per
month) contact with the Practicum Student/Intern to review Practicum/Internship goals,
objectives and activities (including review of Practicum/Internship log). This may be
accomplished by telephone or email, or may be undertaken face-to-face.

The Field Supervisors will provide the University Practicum/Internship Coordinator with (a) a
written evaluation of the Practicum Student/Intern’s performance and (b) work samples that are
indicative of the Practicum Student/Intern’s performance at least twice during the
Practicum/Internship experience (by ______________MID POINT DATE and
______________END DATE). On the basis of the work samples and information received from
the Field Supervisor as well as the Practicum Student/Intern, the University Supervisor will
determine and submit a Pass/Fail mark for the Practicum/Internship (e.g. EPSE 598; EPSE 689)
to the University of British Columbia by ____DATE.

Practicum Student/Intern: ________________________________                        _
Practicum Student/Intern Signature __________________________ Date __________

Primary Field Supervisor: __________________________________
Primary Field Supervisor Signature: __________________________ Date _________________

University Practicum/Intern Coordinator: _____________________________________
University Practicum/Internship
Coordinator Signature:                                           Date

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