Site Supervisor Information Form

The purpose of this form is to gather information relevant for our students' placements and to ensure our seamless contact throughout the clinical field placement experience.

Name Name First Last
Site Name
I have read the most recent edition of the EDC Site Supervisor's Clinical Manual and understand the roles and responsibilities described within it.

I have read the most recent edition of the EDC Site Supervisor's Clinical Manual and understand the roles and responsibilities described within it. Yes No
I completed this form within the last six months, and my information has not changed. If Yes, please click submit. If No, please complete the remainder of this form.

I completed this form within the last six months, and my information has not changed. If Yes, please click submit. If No, please complete the remainder of this form. Yes No
Job Title
I earned a minimum of a masters degree in counseling or a related educational field (e.g. psychology, social work, psychiatry, etc.)

I earned a minimum of a masters degree in counseling or a related educational field (e.g. psychology, social work, psychiatry, etc.) Yes No
If Yes, please identify the name of the degree and the university from which you earned it.
I completed training in counseling supervision (e.g. graduate-level course, workshop, continuing education training, etc.).

I completed training in counseling supervision (e.g. graduate-level course, workshop, continuing education training, etc.). Yes No
If Yes, please identify the full title of the course or training and the source that provided it.
I have worked at this site for a minimum of two years.

I have worked at this site for a minimum of two years. Yes No
Site Address Site Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Work Phone Work Phone - ### - ### ####
Fax Fax - ### - ### ####
Work Email
Site Web Site
Certifications/ Licenses

Certifications/ Licenses Provisionally Certified School Counselor Permanently Certified School Counselor Licensed Mental Health Counselor Licensed Clinical Social Worker Licensed Clinical Psychologist Nationally Certified Counselor Nationally Certified School Counselor Nationally Certified Clinical Mental Health Counselor CASAC-T CASAC Other Other
By typing out my name below, I understand this is a legal representation of my signature.