Internship Agreement - MHC - Page 1 of 5 (Agreement)

Internship Agreement - MHC

Department of Counselor Education.

Page 1 of 5 - Agreement

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The purpose of this Internship Agreement Form is to define clearly the expectations, learning objectives, and evaluation criteria of the Site, Site Supervisor, Intern, and the Department.
AGREEMENT
Recognizing the importance and mutual benefit of clinical field placements, this Internship Agreement Form is a cooperative – joint agreement established between the SUNY Brockport Counselor Education Department (hereafter referred to as "Department"), and
Name of site

Hereafter referred to as site.
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Site Supervisor Name Site Supervisor Name First Middle Last
Hereafter referred to as the "Supervisor".
Site Supervisor Phone Number
Must be 10 digits. Currently Entered: 0 digits.
Numbers only. Do not enter dashes or parentheses.
Site Supervisor Email
Site Supervisor License Category and License number. (LMHC, LCSW, LCSW-R , or Higher Education and Student Affairs)
This relationship is established for the purposes of the intern completing an internship at the identified site/s during the identified semesters.
Intern Name Intern Name First Middle Last
Hereafter referred to as the "Intern".
Intern Email

Please use your college ( @brockport.edu ) email address.
Intern Phone Number
Must be 10 digits. Currently Entered: 0 digits.
Numbers only. Do not enter dashes or parentheses.
The agreed upon start and end dates for the Internship field placement.

*Note that while your start and end dates may span two semesters, there will be a separate interim contract needed for the time between the end date of the first semester and the start date of the second semester. The Clinical Coordinator will send out the link for interim contracts as the end of the semester approaches. For more information about the SUNY Brockport academic calendar, click here.
Start Date: Start Date: / MM / DD YYYY
End Date: End Date: / MM / DD YYYY
The collaboratively agreed upon weekdays and hours the EDC student will be onsite are as follows:

Note: Please include these as the specific weekdays and hours. For example:
Day One: Mondays from 7am - 3pm
Day Two: Wednesdays from 7-11am

Of the 20 hours the student is required to be onsite for internship, it must include at least one full business day.
Day One
Day Two
Day Three
Day Four (if needed)
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Internship Agreement - MHC

Page 1 of 5 - Agreement

The purpose of this Internship Agreement Form is to define clearly the expectations, learning objectives, and evaluation criteria of the Site, Site Supervisor, Intern, and the Department.

AGREEMENT

Recognizing the importance and mutual benefit of clinical field placements, this Internship Agreement Form is a cooperative – joint agreement established between the SUNY Brockport Counselor Education Department (hereafter referred to as "Department"), and

This relationship is established for the purposes of the intern completing an internship at the identified site/s during the identified semesters.

The agreed upon start and end dates for the Internship field placement.

The collaboratively agreed upon weekdays and hours the EDC student will be onsite are as follows: